Evaluating the Vestibulo-Ocular Reflex Following Traumatic Brain Injury: A Scoping Review.

Purpose:To identify the tests and tools used to evaluate vestibulo-ocular reflex (VOR) function after traumatic brain injury (TBI) in all age groups and across TBI severity.Methods: An electronic search was conducted to include relevant peer-reviewed literature published up to November 2019. Studies included those done with humans, of all ages, and had assessments of oculomotor and/or vestibulo-ocular function in TBI.Results: Of the articles selected (N = 48), 50% were published in 2018/2019. A majority targeted mild TBI, with equal focus on non-computerized versus computerized measures of VOR. Computerized assessment tools used were videonystagmography, dynamic visual acuity/gaze stability, rotary chair, and caloric irrigation. Non-computerized tests included the head thrust, dynamic visual acuity, gaze stability, head shaking nystagmus, rotary chair tests and the vestibular/oculomotor screening tool. High variability in administration protocols were identified. Namely: testing environment, distances/positioning/equipment used, active/passive state, procedures, rotation frequencies, and variables observed.Conclusions: There is a rapid growth of literature incorporating VOR tests in mild TBI but moderate and severe TBI continues to be under-represented. Determining how to pair a clinical test with a computerized tool and developing standardized protocols when administering tests will help in developing an optimal battery assessing the VOR in TBI.

Prevalence of traumatic brain injury and epilepsy among prisoners in France: Results of the Fleury TBI study.

OBJECTIVE: The first aim of this study was to estimate the prevalence of TBI and epilepsy in a French prison population and to study variables known to be associated with TBI. The second aim was to compare prisoners with and without a history of TBI. PARTICIPANTS: All offenders (females, males and juveniles) admitted consecutively to Fleury-Mérogis prison over a period of 3 months were included in the study. DESIGN: During the admission procedure, offenders were interviewed by healthcare staff using a self-reported questionnaire. RESULTS: In all, 1221 prisoners were included. The rates of TBI and epilepsy were high, with a prevalence of 30.6% and 5.9%, respectively. Psychiatric care, anxiolytic and antidepressant treatment, use of alcohol and cannabis were all significantly higher among offenders with a history of TBI. Moreover, the number of times in custody and the total time spent in jail over the preceding 5 years were significantly higher among offenders with a history of TBI. CONCLUSIONS: These results provide further evidence that specific measures need to be developed such as, first of all, screening for TBI upon arrival in prison.

Assessment of executive functioning in children and young adults treated for frontal lobe tumours using ecologically valid tests.

There is a lack of studies assessing executive functions (EF) using ecologically valid tests in children with frontal lobe lesions. This study aimed to (1) evaluate EF in children, adolescents and young adults treated for childhood frontal lobe tumours, (2) identify factors influencing performance, such as age at diagnosis or type of treatment, and (3) examine correlations between intellectual ability and classical and ecological tests of EF. Twenty-one patients, aged 8-27 years, treated for a childhood benign or malignant frontal lobe tumour, and 42 healthy controls (matched for gender, age and socio-economic status) were assessed using classical tests of EF, and the BADS-C ecological battery. Patients also underwent assessment of intellectual ability and parent and teacher ratings of the BRIEF questionnaire. IQ scores ranged from 45 to 125 (mean FSIQ = 84) and were lower in case of epilepsy, hydrocephalus and lower parental education. Patients displayed deficits in most, but not all measures of EF. Most classical and ecological measures of EF were strongly correlated to IQ. This study confirms the frequency of EF deficits in this population; it also highlights the utility of ecological measures of EF and some limitations of classical tests of EF in children.

Quality-of-life, mood and executive functioning after childhood craniopharyngioma treated with surgery and proton beam therapy.

PRIMARY OBJECTIVE: Childhood craniopharyngioma, a benign tumour with a good survival rate, is associated with important neurocognitive and psychological morbidity, reducing quality-of-life (QoL). METHOD: This retrospective study analysed QoL, mood disorders, everyday executive functioning and disease's impact on family life in 29 patients (mean age at diagnosis 7 years 10 months (SD = 4.1); mean follow-up period 6 years 2 months (SD = 4.5)) treated for childhood craniopharyngioma by surgery combined with radiotherapy using proton beam. Assessment included a semi-structured interview and standardized scales evaluating self-report of QoL (Kidscreen 52) and depression (MDI-C) and proxy-reports of QoL (Kidscreen 52), executive functioning (BRIEF) and disease's impact (Hoare and Russel Questionnaire). RESULTS: Twenty-three families answered the questionnaires completely. Overall QoL self-report was within the normal range. QoL proxy-report was lower than self-report. Eleven patients reported depression; 24-38% had dysexecutive symptoms. A majority of families felt 'very concerned' by the disease. Depression and low parental educational level were associated with lower QoL and higher levels of executive dysfunction. CONCLUSION: Given the high morbidity of childhood craniopharyngioma, screening for psychosocial outcome, cognitive functioning, including executive functions, mood and QoL should be systematic and specific interventions should be developed and implemented.

Neuropsychological consequences of childhood medulloblastoma and possible interventions: A review.

BACKGROUND: Children who have been treated for a medulloblastoma often suffer long-term cognitive impairments that often negatively affect their academic performance and quality of life. In this article, we will review the neuropsychological consequences of childhood medulloblastoma and discuss the risk factors known to influence the presence and severity of these cognitive impairments and possible interventions to improve their quality of life. METHODS: This narrative review was based on electronic searches of PubMed to identify all relevant studies. RESULTS: Although many types of cognitive impairments often emerge during a child's subsequent development, the core cognitive domains that are most often affected in children treated for a medulloblastoma are processing speed, attention and working memory. The emergence and magnitude of these deficits varies greatly among patients. They are influenced by demographic (age at diagnosis, parental education), medical and treatment-related factors (perioperative complications, including posterior fossa syndrome, radiation therapy dose, etc.), and the quality of interventions such as school adaptations provided to the child or rehabilitation programs that focus on cognitive skills, behavior and psychosocial functioning. CONCLUSION: These patients require specialized and coordinated multidisciplinary rehabilitation follow-up that provides timely and adapted assessments and culminates in personalized intervention goals being set with the patient and the family. Follow-up should be continued until referral to adult services.

A comprehensive model of care for rehabilitation of children with acquired brain injuries.

BACKGROUND: Acquired brain injury (ABI) is a leading cause of death and lifelong acquired disability in children and remains a significant public health issue. Deficits may only become fully apparent when developmental demands increase and once cognitive processes are expected to be fully developed. It is therefore necessary to provide organized long-term follow-up for children post ABI. Despite these recommendations, it has been shown that only a small proportion of children received specialized rehabilitation and adequate follow-up after ABI. AIMS: The aims are: (i) to describe a comprehensive model of care devoted to children with acquired brain injuries; and (ii) to provide descriptive data analysing the characteristics of children followed up, the type/amount of services provided and general outcomes. PROGRAMME DESCRIPTION: The programme features an in- and outpatient rehabilitation facility, where multidisciplinary rehabilitation and specialized schooling are provided. The ultimate goal of the programme is to promote each child's successful reintegration in school and in the community. Adequate preparation of discharge is essential, long-term follow-up is organized, and an outreach programme has been developed to deal with the complex delayed psychosocial issues. RESULTS: Overall outcome, as measured by the Glasgow Outcome Scale, improved dramatically between admission (3.3; SD = 0.45) and discharge (2.15; SD = 0.74). Most of the children were discharged home with an adequate personalized plan for ongoing rehabilitation and school adaptations. Analysis of the outreach programme underlines the more challenging issues arising in late adolescence-early adulthood. CONCLUSION: Given the specificities of childhood ABI, long-term specific care must be organized and co-ordinated, regardless of injury severity.

Quality of survival assessment in European childhood brain tumour trials, for children below the age of 5 years.

The highest incidence rate of childhood brain tumours is in children below the age of five years, who are particularly vulnerable to the effects of treatments. The assessment of quality of survival (QoS) in multiple domains is essential to compare the outcomes for different tumour types and treatment regimens. The aim of this position statement is to present the domains of health and functioning to be assessed in children from birth to five years, to advance the collection of a common QoS data set in European brain tumour trials. The QoS group of the European Society of Paediatric Oncology (SIOP-E) Brain Tumour group conducted consensus discussions over a period of six years to establish domains of QoS that should be prioritised in clinical trials involving children under 5 years. The domains of health and functioning that were agreed to affect QoS included: medical outcomes (e.g. vision, hearing, mobility, endocrine), emotion, behaviour, adaptive behaviour, and cognitive functioning. As for children aged five years and older, a 'core plus' approach is suggested in which core assessments are recommended for all clinical trials. The core component for children from birth to three years includes indirect assessment which, in this age-group, requires proxy assessment by a parent, of cognitive, emotional and behaviour variables and both direct and indirect endocrine measures. For children from four years of age direct cognitive assessment is also recommended as 'core'. The 'plus' components enable the addition of assessments which can be selected by individual countries and/or by, age-, treatment-, tumour type- and tumour location-specific trials.

From childhood to adulthood: long-term outcome of medulloblastoma patients. The Institut Curie experience (1980-2000).

Medulloblastoma patients treated at the Institute Curie between 1980 and 2000 were reviewed. Only patients whose primary treatment included craniospinal radiation were considered. Surviving patients were identified and evaluated by means of self-report questionnaires using the Health Utility Index (HUI). Psychosocial functioning, employment, and other health-related indicators were recorded. Seventy-three patients were treated during the study period. At a median follow-up from diagnosis of 14.4 years, 49 patients were alive and 45 surviving patients could be contacted. Late sequelae were frequent, particularly neurological deficits (71%) and endocrine complications (52%). Impairments of psychosocial functioning, including employment, driving capacity, independent living, and marital status, were identified in most patients. Most long-term medulloblastoma survivors suffer persistent deficits in several domains, with a significant impact on their psychosocial functioning. These findings reinforce the importance of early intervention programs for all survivors in order to reduce the psychosocial impacts of their disease.

Abusive head trauma, healthcare, and childhood professionals' lack of knowledge is detrimental to the child's interest.

OBJECTIVE: To assess the knowledge of professionals on abusive head trauma (AHT) and shaking so as to adapt their training and thus promote the improvement of AHT screening and prevention. METHOD: A questionnaire was developed on the knowledge of the intensity of movement, the frequency of repetition, the existence and progression of sequelae over time, the legal nature of AHT as a criminal offence leading to the possibility of compensation, and the existence of HAS (French National Authority for Health) recommendations on shaken baby diagnosis and legal consequences. RESULTS: Over a 4-year period 311 physicians, 123 magistrates, and 644 early childhood professionals responded to the questionnaire as an introduction to a course on AHT. Whatever the professional field, incorrect answers (wrong or "I don't know") were frequent as to the possibility that play could induce AHT lesions (51-58%), the violence of the act (43-52%), the repetition of shaking (58-82.5%), the presence of side effects (52-58%), and the existence of recommendations to professionals (48-58.5%). Twenty to 47% of physicians and early childhood professionals were unaware that shaking a baby was a criminal offence and 20-27% were unaware that AHT required a report to the judicial authorities. DISCUSSION/CONCLUSION: This lack of knowledge about AHT is detrimental to the child. The improvement of initial and continuing education is necessary to help reduce the dysfunctions existing in the care of child victims of AHT.

The European Society of Paediatric Oncology Ependymoma-II program Core-Plus model: Development and initial implementation of a cognitive test protocol for an international brain tumour trial.

It is increasingly accepted that survival alone is an inadequate measure of the success of childhood brain tumour treatments. Consequently, there is growing emphasis on capturing quality of survival. Ependymomas are the third most frequently occurring brain tumours in childhood and present significant clinical challenges. European Society of Paediatric Oncology Ependymoma II is a comprehensive international program aiming to evaluate outcomes under different treatment regimens and improve diagnostic accuracy. Importantly, there has been agreement to lower the age at which children with posterior fossa ependymoma undergo focal irradiation from three years to either eighteen months or one year of age. Hitherto radiotherapy in Europe had been reserved for children over three years due to concerns over adverse cognitive outcomes following irradiation of the developing brain. There is therefore a duty of care to include longitudinal cognitive follow-up and this has been agreed as an essential trial outcome. Discussions between representatives of 18 participating European countries over 10 years have yielded European consensus for an internationally accepted test battery for follow-up of childhood ependymoma survivors. The 'Core-Plus' model incorporates a two-tier approach to assessment by specifying core tests to establish a minimum dataset where resources are limited, whilst maintaining scope for comprehensive assessment where feasible. The challenges leading to the development of the Core-Plus model are presented alongside learning from the initial stages of the trial. We propose that this model could provide a solution for future international trials addressing both childhood brain tumours and other conditions associated with cognitive morbidity.

[The effect of age on executive functioning after acquired brain injury in adults]. / Effet de l'âge sur le fonctionnement exécutif après lésion cérébrale chez l'adulte.

INTRODUCTION: Executive functioning deficits have often been described in normal aging. They are also known to be a frequent sequel of traumatic brain injury, where patients may exhibit severe long-standing impairments in instrumental activities of daily living. One could therefore expect that cerebral lesions affecting executive functioning would result in more severe impairments in older patients. We previously developed an ecological assessment of executive functions, consisting of a cooking task, requiring multitasking abilities and known to be sensitive to a dysexecutive syndrome [Cortex 36 (2000) 649-669]. The aim of this study was to analyze the effect of age on the cognitive and ecological assessments of executive functions in a group of patients with acquired brain injury (ABI) resulting in a dysexecutive syndrome. Studies in this area usually focus on patients older than 60 or 65, but we chose to analyze the effect of age in a younger population. We hypothesized that older patients would have poorer performances on the cognitive and ecological tests of executive functioning, when compared to younger patients. METHODS: Forty-five patients with ABI resulting in frontal lesions and a dysexecutive syndrome participated in this study. Patients underwent a comprehensive battery of cognitive tests assessing executive functioning, as well as the cooking task. We also studied a group of 12 control subjects who performed the cooking task. RESULTS: No effect of age was found on performance in the cooking task in the control group. Age was not related to demographic parameters or injury severity in the ABI group. Although the ABI group was relatively young (mean age: 40.3 years (S.D.=12.5), ranging from 17 to 63), results indicated a significant deleterious effect of age on the cognitive tests of executive functioning in the ABI group. We also highlighted a significant worsening of patients' performance in the cooking task with age, and this effect was found on several variables of task analysis: the number of errors and occurrence of dangerous behaviors. CONCLUSION: Our study demonstrates the deleterious effect of aging on cognitive and ecological assessment of executive functioning after ABI. The strength of this study is that it deviated from the traditional age considered in studies of elderly populations and focused on younger patients. It is therefore important to consider the implication that this may have on a patient's rehabilitation program and postinjury discharge.

[Ecological assessment of executive functions in a patient with acquired brain injury]. / Evaluation écologique des fonctions exécutives chez un patient traumatisé crânien.

UNLABELLED: Dysexecutive syndrome is one of the most frequent sequel of severe traumatic brain injury. It causes severe disabilities and it is incompletely assessed by the classical "paper and pencil" neuropsychological tests. We developed an ecological assessment conducted in a naturalistic situation, consisting of a cooking task, and we described a classification of errors. This assessment is very sensitive, even to a mild dysexecutive syndrome. OBJECTIVE: To describe the disabilities in activities of daily living of a traumatic brain-injured patient and to demonstrate the sensitivity of an ill-structured ecological assessment. METHOD: We report a single case study illustrating how the ecological assessment by the cooking task helped better understand and characterize the patient's disabilities. RESULTS: The patient presented severe disabilities in daily life activities, which were well described by his family. His cognitive disorders were mild in the cognitive tests, even those supposed to be more ecological, such as the Six Elements Task or script generation. He exhibited very severe disorders in the cooking task, with a very high number of errors. Moreover, duration of the cooking task was very long; he did not achieve the goal and exhibited dangerous behaviour. DISCUSSION AND CONCLUSION: The cooking task involves abilities to deal with multitasking, which particularly involve executive functions. The most severe disorders were observed during the patient's interaction with the environment while conducting a complex goal-directed action plan, indicating control disorders. This type of naturalistic assessment provides very useful information to help patients organise their familial, social or professional reintegration.

[The effectiveness of constraint-induced movement therapy for children with hemiplegia following acquired brain injury]. / Intérêt de la thérapie par contrainte induite chez l'enfant hémiplégique après lésion cérébrale acquise.

UNLABELLED: Constraint-induced movement therapy is a promising technique for improving upper limb function in adults with hemiplegia. It involves restraint of the non-involved limb and intensive movement practice with the paretic limb. Although the technique has been applied successfully to children with cerebral palsy, only two studies have used it in children with acquired brain injury. OBJECTIVE: To assess the feasibility and efficacy of constraint-induced movement therapy in children with acquired brain injury. METHODS: We used a single-subject experimental design in three children (aged five at the time of the intervention) with hemiplegia in the chronic phase following acquired brain injury. The intervention involved restraint of the unaffected arm with a Mayo Clinic elbow brace for seven hours a day in a hospital setting, together with three hours a day of physical and occupational therapy rehabilitation for five days a week for two weeks. The children were assessed twice at baseline and then once immediately post-treatment and again two months post-treatment. Assessment included a range of timed, quantitative measures of upper limb use, assessment of unilateral spatial neglect and qualitative assessment by therapists and parents in terms of activities of daily living. RESULTS: The three children completed the full protocol and improved significantly in all timed, quantitative tests of motor function. These improvements were partially maintained at two months. No improvement in unilateral spatial neglect was found in the paper-and-pencil tasks, although less spatial neglect was observed in activities of daily living such as eating and walking. CONCLUSION: Constraint-induced movement therapy appears to be both feasible and efficient in children with acquired brain injury.

History of traumatic brain injury in prison populations: A systematic review.

Traumatic brain injury (TBI) can lead to cognitive, behavioural and social impairments. The relationship between criminality and a history of TBI has been addressed on several occasions. OBJECTIVE: The objective of this review was to present an update on current knowledge concerning the existence of a history of TBI in prison populations. METHODS: PubMed and PsycINFO databases were searched for relevant papers, using the PRISMA guidelines. We selected papers describing TBI prevalence among incarcerated individuals and some that also discussed the validity of such studies. RESULTS: Thirty-three papers were selected. The majority of the papers were on prison populations in Australia (3/33), Europe (5/33) and the USA (22/33). The selected studies found prevalence rates of the history of TBI ranging from 9.7% and 100%, with an average of 46% (calculated on a total population of 9342). However, the level of evidence provided by the literature was poor according to the French national health authority scale. The majority of the prisoners were males with an average age of 37. In most of the papers (25/33), prevalence was evaluated using a questionnaire. The influence of TBI severity on criminality could not be analysed because of a lack of data in the majority of papers. Twelve papers mentioned that several comorbidities (mental health problems, use of alcohol…) were frequently found among prisoners with a history of TBI. Two papers established the validity of the use of questionnaires to screen for a history of TBI. CONCLUSION: These results confirmed the high prevalence of a history of TBI in prison populations. However, they do not allow conclusions to be drawn about a possible link between criminality and TBI. Specific surveys need to be performed to study this issue. The authors suggest ways of improving the screening and healthcare made available to these patients.

Feasibility of a shorter Goal Attainment Scaling method for a pediatric spasticity clinic - The 3-milestones GAS.

BACKGROUND: Goal Attainment Scaling (GAS) is a method for writing personalized evaluation scales to quantify progress toward defined goals. It is useful in rehabilitation but is hampered by the experience required to adequately "predict" the possible outcomes relating to a particular goal before treatment and the time needed to describe all 5 levels of the scale. Here we aimed to investigate the feasibility of using GAS in a clinical setting of a pediatric spasticity clinic with a shorter method, the "3-milestones" GAS (goal setting with 3 levels and goal rating with the classical 5 levels). Secondary aims were to (1) analyze the types of goals children's therapists set for botulinum toxin treatment and (2) compare the score distribution (and therefore the ability to predict outcome) by goal type. METHODS: Therapists were trained in GAS writing and prepared GAS scales in the regional spasticity-management clinic they attended with their patients and families. The study included all GAS scales written during a 2-year period. GAS score distribution across the 5 GAS levels was examined to assess whether the therapist could reliably predict outcome and whether the 3-milestones GAS yielded similar distributions as the original GAS method. RESULTS: In total, 541 GAS scales were written and showed the expected score distribution. Most scales (55%) referred to movement quality goals and fewer (29%) to family goals and activity domains. CONCLUSION: The 3-milestones GAS method was feasible within the time constraints of the spasticity clinic and could be used by local therapists in cooperation with the hospital team.

An ecological approach to planning dysfunction: script execution.

Planning, which concerns many activities in everyday life, is a two-stage process. The first one predetermines a course of actions aimed at achieving some specific goals. It is founded on managerial knowledge or overlearned sequences of events and may be tested by script generation. The second stage entails monitoring and guiding the execution of the plan to a successful conclusion. It must take into account environmental contingencies and may be tested by script execution. If the frontal lobes intervene not only in managerial knowledge (Grafman, 1989) but also in binding the plan with contextual environment (Damasio, Tranel and Damasio, 1991; Shallice and Burgess, 1991), script execution would be more sensitive than script generation to planning deficits. To test this hypothesis, script execution and script generation were compared in 11 patients with a dysexecutive syndrome and 10 matched controls, using three scripts of daily life activities: (1) 'shopping for groceries'; (2) 'cooking'; (3) 'answering a letter and finding the way to post the reply'. Two way ANOVAs showed more errors in execution than in generation, more errors in patients than in controls, and a greater difference between execution and generation in patients than in controls. Furthermore, 'context neglect' and 'environmental adherence' were the two types of errors that best differentiated patients from controls. Finally, the total number of errors in execution correlated with the score on behavioral questionnaires answered by occupational therapists. These results confirm our hypothesis and suggest that script execution may be a valid ecological approach to estimate the severity of deficits in daily life activities.

[Unilateral spatial and motor neglect in children]. / Négligence spatiale unilatérale et motrice chez l'enfant.

Although unilateral spatial neglect is well documented in adults after a cerebral damage, the description in children is rare and no motor neglect has yet been reported. We report four children age range from three to thirteen years old, in patients in a rehabilitation department. A cancellation task "the Teddy bear test" was used to assess spatial neglect in children. The children were presented a page containing line drawings of usual objects, including fifteen Teddy bears. The children were asked to cross out each Teddy bear. These four children omitted five to eleven teddy bears located on the left space, whereas children of the controlled group never omitted more than one Teddy bear. The four children also exhibited neglect in drawings, and during daily life activities. Moreover, one of them had a motor neglect with no more defects of strength and an under-utilization of his left side. Spatial unilateral neglect and motor neglect should be systematically investigated in children after a cerebral damage, and should be considered during rehabilitation.

[Spontaneous muscular haematomas in hemiplegic patients receiving anticoagulation therapy]. / Hématomes musculaires spontanés chez les patients hémiplégiques sous traitement anticoagulant.

INTRODUCTION: Muscular hematomas are frequently reported as a complication of anticoagulation therapy. METHODS: We report six cases of spontaneous muscular hematomas occurring in hemiplegic patients receiving anticoagulation therapy using heparin, low-molecular-weight heparin or fluindione. Anticoagulation therapy was given in prophylactic doses to two patients to prevent deep vein thrombosis and in therapeutic doses to four patients with deep vein thrombosis, pulmonary embolism or cardiac arrhythmia. Two patients experienced episodes of bleeding when heparin and fluindione were temporarily associated. RESULT: Contrary to previous reports, the more frequent site of bleeding was not the ilio-psoas muscle (only 2 patients); hematomas were also observed in hip adductors and gluteus muscles. The most striking finding was the constant location of the hematoma on the hemiplegic side. CONCLUSION: Location on the hemiplegic side can lead to underestimating the frequency of neurologic compression by the hematoma; the diagnosis can nevertheless be established by electromyography. Local signs may not be present, but general signs of hypovolemia and anemia are more frequent. Ultrasound may be the first line investigation but in our experience, the results can be misleading and computed tomography (CT) or MRI are often required to confirm the diagnosis.

Goal attainment scaling in rehabilitation: a literature-based update.

Goal Attainment Scaling (GAS) is a method for quantifying progress on personal goals. Turner-Stokes's guide to GAS is a method for quantifying progress towards personal goals. Turner-Stokes's guide and the use of Kiresuk's T-score are the most widely used GAS-based approaches in rehabilitation. However, the literature describes a number of other approaches and emphasizes the need for caution when using the T-score. This article presents the literature debates on GAS, variations of GAS (in terms of the score level assigned to the patient's initial status and description of the scale's different levels), the precautions to be taken to produce valid GAS scales and the various ways of analyzing GAS results. Our objective is to (i) provide clinical teams with a critical view of GAS (the application of which is not limited to a single research group's practices) and (ii) present the most useful resources and guidelines on writing GAS scales. According to the literature, it appears to be preferable to set the patient's initial level to -2 (even when worsening is a possible outcome) and to describe all five GAS levels in detail. The use of medians and rank tests appears to be appropriate, given the ordinal nature of GAS.