Body-weight support gait training in neurological intensive care: safety, feasibility, and delays before walking with or without suspension.

BACKGROUND: Early Mobilization in Intensive Care Units (ICUs) enhances patients' evolution, but has been rarely studied in neurological ICUs. The aim of this study was to assess gait training with body-weight support (BWS) in neuroICU, and to report on its safety, feasibility and on delays before walking with and without BWS. METHODS: This study was an observational one-year single-center study. Inclusion criteria were adults with a neurological injury requiring mechanical ventilation. Exclusion criteria were early death or ICU transfer. After weaning from ventilation, patients were screened for indications of BWS walking using predefined criteria. RESULTS: Patients' conditions were mostly brain injuries: 32% subarachnoid hemorrhages, 42% focal strokes, and 12% traumatic brain injuries. Out of 272 admissions, 136 patients were excluded, 78 were eligible, and 33 performed BWS walking. Among non-eligible patients, 36 walked unsuspended upon ventilation weaning, 17 presented too severe impairments. Among the 45 eligible patients who did not receive BWS training, main reasons were workload and weekends (31%), medical barriers (29%), and early ICU discharge (22%). 78 BWS sessions were performed on the 33 beneficiaries (median sessions per patient 2, max 10). Pre-session, most patients had inadequate response to pain, orders, or simple orientation questions. Sitting without support was impossible for 74%. Most pre-post changes in hemodynamic, respiratory, and pain parameters were small, and recovered spontaneously after the session. Eight sessions were interrupted; reasons were pain, fatigue or major imbalance (4), syncope (1), occurrence of stool (2), and battery failure (1). None of these adverse events required medical intervention, patients recovered upon session interruption. Median session duration was 31 min, patients walked on median 17 m. First BWS session occurred on median 3 days after ventilation weaning, and 11 days before patients were able to walk unsuspended. CONCLUSIONS: Verticalization and walking using a suspension device in patients in neuroICU allows early gait training, despite challenging neurological impairments. It is safe and generally well tolerated. TRIAL REGISTRATION: ClinicalTrials database (ID: NCT04300491).

Relationships between neuropsychological impairments and functional outcome eight years after severe traumatic brain injury: Results from the PariS-TBI study.

BACKGROUND/OBJECTIVES: The objective was to assess the relationships between neuropsychological impairments, functional outcome and life satisfaction in a longitudinal study of patients after a severe traumatic brain injury (TBI) (PariS-TBI study). PATIENTS: Out of 243 survivors, 86 were evaluated 8 years post-injury. They did not significantly differ from patients lost-to-follow up except for the latter being more frequently students or unemployed before the injury. METHODS: Outcome measures included the Glasgow Outcome Scale-Extended (GOS-E), a functional independence questionnaire, employment, mood, fatigue and satisfaction with life. Neuropsychological outcome was assessed by two ways: performance-based outcome measures, using neuropsychological tests and patient and relative-based measures. RESULTS: Neuropsychological measures were not significantly related to initial injury severity nor to gender, but were significantly related to age and education. After statistical correction for multiple comparisons, cognitive testing and cognitive questionnaires were significantly correlated with most outcome measures. By contrast, satisfaction with life was only related with patient-rated questionnaires. A regression analysis showed that the Trail-Making-Test-A was the best predictor of functional outcome, in addition to education duration. CONCLUSIONS: Cognitive measures, particularly slowed information processing speed, were significant indicators of functional outcome at a long-term post-injury, beyond and above demographics or injury severity measures.

Practitioners' opinions on traumatic brain injury care pathways in Finland and France: different organizations, common issues.

OBJECTIVE: In traumatic brain injury (TBI), differences in health-care contexts have profound effects on care pathways. Objectives were to compare TBI pathways of care and practitioners' views on quality of care issues in two large European areas: Varsinais-Suomi, Finland and Ile-de-France, France. METHODS: Thematic analysis of semi-structured interviews was conducted with TBI practitioners (n = 10) from all stages of TBI care. Interviews addressed organization and financing of care, decision-making on care transitions, and perceived issues. The structure-process-outcome model of Donabedian was used to classify findings related to quality of care issues. RESULTS: Main differences in organization of care pathways for people with TBI were related to financing modalities, number of pathway alternatives, inpatient versus outpatient rehabilitation, and indirect versus direct referrals to rehabilitation. Similar categories of issues were raised in the two settings. Issues in structures involved availability of services, financial access, and heterogeneity of expertise. Issues in processes involved diagnosis and follow-up, training regarding cognitive impairments, decision-making for referrals, transition delays, and care pathways of very severely affected patients. CONCLUSIONS: These findings provide clues to address care pathways in further comparative studies. Determinants of care pathway quality could be classified as direct or indirect, binding or adaptive organizational factors.

Upper Limb Isokinetic Strengthening Versus Passive Mobilization in Patients With Chronic Stroke: A Randomized Controlled Trial.

OBJECTIVE: To assess the benefit of isokinetic strengthening of the upper limb (UL) in patients with chronic stroke as compared to passive mobilization. DESIGN: Randomized blinded assessor controlled trial. SETTING: Physical Medicine and Rehabilitation departments of 2 university hospitals. PARTICIPANTS: Patients (N=20) with incomplete hemiplegia (16 men; mean age, 64y; median time since stroke, 32mo). INTERVENTIONS: A 6-week comprehensive rehabilitation program, 3d/wk, 3 sessions/d. In addition, a 45-minute session per day was performed using an isokinetic dynamometer, with either isokinetic strengthening of elbow and wrist flexors/extensors (isokinetic strengthening group) or passive joint mobilization (control group). MAIN OUTCOME MEASURES: The primary endpoint was the increase in Upper Limb Fugl-Meyer Assessment (UL-FMA) score at day 45 (t1). Secondary endpoints were increases in UL-FMA scores, Box and Block Test scores, muscle strength, spasticity, and Barthel Index at t1, t2 (3mo), and t3 (6mo). RESULTS: Recruitment was stopped early because of excessive fatigue in the isokinetic strengthening group. The increase in UL-FMA score at t1 was 3.5±4.4 in the isokinetic strengthening group versus 6.0±4.5 in the control group (P=.2). Gains in distal UL-FMA scores were larger (3.1±2.8) in the control group versus 0.6±2.5 in the isokinetic strengthening group (P=.05). No significant group difference was observed in secondary endpoints. Mixed models confirmed those results. Regarding the whole sample, gains from baseline were significant for the UL-FMA at t1 (+4.8; P<.001), t2, and t3 and for the Box and Block Test at t1 (+3; P=.013) and t2. CONCLUSIONS: In a comprehensive rehabilitation program, isokinetic strengthening did not show superiority to passive mobilization for UL rehabilitation. Findings also suggest a sustained benefit in impairments and function of late UL rehabilitation programs for patients with stroke.

Self-awareness four years after severe traumatic brain injury: discordance between the patient's and relative's complaints. Results from the PariS-TBI study.

OBJECTIVE: To evaluate the patient's awareness of his or her difficulties in the chronic phase of severe traumatic brain injury (TBI) and to determine the factors related to poor awareness. DESIGN/SETTING/SUBJECTS: This study was part of a larger prospective inception cohort study of patients with severe TBI in the Parisian region (PariS-TBI study). Intervention/Main measures: Evaluation was carried out at four years and included the Brain Injury Complaint Questionnaire (BICoQ) completed by the patient and his or her relative as well as the evaluation of impairments, disability and quality of life. RESULTS: A total of 90 patient-relative pairs were included. Lack of awareness was measured using the unawareness index that corresponded to the number of discordant results between the patient and relative in the direction of under evaluation of difficulties by the patient. The only significant relationship found with lack of awareness was the subjective burden perceived by the relative (Zarit Burden Inventory) ( r = 0.5; P < 0.00001). There was no significant relationship between lack of awareness and injury severity, pre-injury socio-demographic data, cognitive impairments, mood disorders, functional independence (Barthel index), global disability (Glasgow Outcome Scale), return to work at four years or quality of life (Quality Of Life after Brain Injury scale (QOLIBRI)). CONCLUSION: Lack of awareness four years post severe TBI was not related to the severity of the initial trauma, sociodemographic data, the severity of impairments, limitations of activity and participation, or the patient's quality of life. However, poor awareness did significantly influence the weight of the burden perceived by the relative.

Percutaneous Needle Tenotomy for the Treatment of Muscle and Tendon Contractures in Adults With Brain Damage: Results and Complications.

OBJECTIVE: To study the results and complications of percutaneous needle tenotomy for superficial retracted tendons in patients with brain damage. DESIGN: Prospective observational study. SETTING: University hospital. PARTICIPANTS: Patients with severe brain damage (N=38; mean age, 60.7y; age range, 24-93y; 21 women) requiring surgical management of contractures and eligible for percutaneous needle tenotomy were enrolled between February 2015 and February 2016. INTERVENTIONS: The percutaneous needle tenotomy gesture was performed by a physical medicine and rehabilitation physician trained by an orthopedic surgeon, under local or locoregional anesthesia. Treated tendons varied among patients. MAIN OUTCOME MEASURES: All patients were evaluated at 1, 3, and 6 months to assess surgical outcomes (joint range of motion [ROM], pain, and functional improvement) while screening for complications. RESULTS: Improvements in ROM (37/38) and contractures-related pain (12/12) were satisfactory. Functional results were satisfactory (Goal Attainment Scale score ≥0) for most patients (37/38): nursing (n=12), putting shoes on (n=8), getting in bed or sitting on a chair (n=6), verticalization (n=7), transfers and gait (n=8), and grip (n=2). Five patients had complications related to the surgical gesture: cast-related complications (n=2), hand hematoma (n=2), and cutaneous necrosis of the Achilles tendon in a patient with previous obliterative arteriopathy of the lower limbs (n=1). CONCLUSIONS: Percutaneous needle tenotomy yields good results in the management of selected superficial muscle and tendon contractures. The complications rate is very low, and this treatment can be an alternative to conventional surgery in frail patients with neurologic diseases.

Late Functional Changes Post-Severe Traumatic Brain Injury Are Related to Community Reentry Support: Results From the PariS-TBI Cohort.

OBJECTIVES: To explore late functional changes after a traumatic brain injury and their relation to patients' characteristics and reentry support. DESIGN: Prospective follow-up of an inception cohort of adults with severe traumatic brain injury recruited in 2005-2007 in the Parisian area, France. One and 4-year assessments were performed by trained neuropsychologists. One-to-4-year change in the Glasgow Outcome Scale-Extended defined 3 groups: "improvement," "stability," and "worsening." Relationships between these groups and patients' characteristics were analyzed. RESULTS: Among 504 recruited patients and 245 four-year survivors, 93 participated in both evaluations. Overall Glasgow Outcome Scale-Extended improved by 0.4. Forty percent of the sample improved, 44% were stable, and 16% worsened. Being in a more unfavorable group was related to preinjury alcohol abuse and to higher anxiety and depression at 4 years. Attendance to a specialized community reentry unit was related to higher chances of being in the "improvement" group in univariate analyses and after adjustment for age, time to follow command, preinjury alcohol and occupation, and mood disorders (adjusted odds ratio [OR] = 4.6 [1.1-20]). CONCLUSION: Late functional changes were related to psychosocial variables and to reentry support. The effect of reentry support on late recovery needs to be confirmed by further investigations.

[From rehabilitation to re-adaptation, preparing the return home]. / De la rééducation à la réadaptation, préparer le retour à domicile.

After a serious head trauma, the return home constitutes a key moment in the patient's reintegration. It is prepared by a multi-disciplinary team throughout the rehabilitation and re-adaptation process, taking into account the patient's prognosis for recovery.

Objective and Subjective Burden of Informal Caregivers 4 Years After a Severe Traumatic Brain Injury: Results From the PariS-TBI Study.

OBJECTIVE: Prospective assessment of informal caregiver (IC) burden 4 years after the traumatic brain injury of a relative. SETTING: Longitudinal cohort study (metropolitan Paris, France). PARTICIPANTS: Home dwelling adults (N = 98) with initially severe traumatic brain injury and their primary ICs. MAIN OUTCOME MEASURES: Informal caregiver objective burden (Resource Utilization in Dementia measuring Informal Care Time [ICT]), subjective burden (Zarit Burden Inventory), monetary self-valuation of ICT (Willingness-to-pay, Willingness-to-accept). RESULTS: Informal caregivers were women (81%) assisting men (80%) of mean age of 37 years. Fifty-five ICs reported no objective burden (ICT = 0) and no/low subjective burden (average Zarit Burden Inventory = 12.1). Forty-three ICs reported a major objective burden (average ICT = 5.6 h/d) and a moderate/severe subjective burden (average Zarit Burden Inventory = 30.3). In multivariate analyses, higher objective burden was associated with poorer Glasgow Outcome Scale-Extended scores, with more severe cognitive disorders (Neurobehavioral Rating Scale-revised) and with no coresidency status; higher subjective burden was associated with poorer Glasgow Outcome Scale-Extended scores, more Neurobehavioral Rating Scale-revised disorders, drug-alcohol abuse, and involvement in litigation. Economic valuation showed that on average, ICs did not value their ICT as free and preferred to pay a mean Willingness-to-pay = &OV0556;17 per hour to be replaced instead of being paid for providing care themselves (Willingness-to-accept = &OV0556;12). CONCLUSION: Four years after a severe traumatic brain injury, 44% of ICs experienced a heavy multidimensional burden.

Loss to Follow-Up and Social Background in an Inception Cohort of Patients With Severe Traumatic Brain Injury: Results From the PariS-TBI Study.

OBJECTIVES: To assess determinants of loss to follow-up (FU) at 2 time points of an inception traumatic brain injury (TBI) cohort. DESIGN AND PARTICIPANTS: The PariS-TBI study consecutively included 504 adults with severe TBI on the accident scene (76% male, mean age 42 years, mean Glasgow Coma Scale 5). No exclusion criteria were used. MAIN MEASURE: Loss to FU at 1 and 4 years was defined among survivors as having no outcome data other than survival status. RESULTS: Among 257 1-year survivors, 118 (47%) were lost to FU at 1 year and 98 (40%) at 4 years. Main reasons for loss to FU were impossibility to achieve contact (109 at 1 year, 52 at 4 years) and refusal to participate (respectively 5 and 24). At 1 year, individuals not working preinjury or with nonaccidental traumas were more often lost to FU in univariate and multivariable analyses. At 4 years, loss to FU was significantly associated with preinjury alcohol abuse and unemployment. Relationship with injury severity was not significant. CONCLUSIONS: Socially disadvantaged persons are underrepresented in TBI outcome research. It could result in overestimation of outcome and biased estimates of sociodemographic characteristics' effects. These persons, particularly unemployed individuals, require special attention in clinical practice.

Disability and health-related quality-of-life 4 years after a severe traumatic brain injury: A structural equation modelling analysis.

OBJECTIVES: To assess predictors and indicators of disability and quality-of-life 4 years after severe traumatic brain injury (TBI), using structural equation modelling (SEM). METHODS: The PariS-TBI study is a longitudinal multi-centre inception cohort study of 504 patients with severe TBI. Among 245 survivors, 147 patients were evaluated upon 4-year follow-up, and 85 completed the full assessment. Two outcome measures were analysed separately using SEM: the Glasgow Outcome Scale-extended (GOS-E), to measure disability, and the QOLIBRI, to assess quality-of-life. Four groups of variables were entered in the model: demographics; injury severity; mood and cognitive impairments; somatic impairments. RESULTS: The GOS-E was directly significantly related to mood and cognition, injury severity, and somatic impairments. Age and education had an indirect effect, mediated by mood/cognition or somatic deficiencies. In contrast, the only direct predictor of QOLIBRI was mood and cognition. Age and somatic impairments had an indirect influence on the QOLIBRI. CONCLUSION: Although this study should be considered as explorative, it suggests that disability and quality-of-life were directly influenced by different factors. While disability appeared to result from an interaction of a wide range of factors, quality-of-life was solely directly related to psycho-cognitive factors.

Sciatic nerve compression by neurogenic heterotopic ossification: use of CT to determine surgical indications.

OBJECTIVE: To describe the characteristics of neurogenic heterotopic ossification (NHO) based on clinical tests, electroneuromyography (ENMG) and CT in a database of patients with lesions of the central nervous system who required sciatic nerve neurolysis along with posterior hip NHO resection, and to determine the respective roles of ENMG and CT in the management of posterior hip NHOs in patients who are unable to communicate or express pain. METHODS: The consistency of the ENMG results with clinical findings, CT results and macroscopic signs of lesions was retrospectively assessed after sciatic nerve neurolysis and ablation of 55 posterior hip NHOs. RESULTS: Sciatic nerve neurolysis was necessary in 55 cases (47.4%; 55 out of 116). CT showed contact of the NHO with the nerve in all cases: 5 in contact with no deflection, 3 in contact with deflection, 21 moulded into a gutter and 26 entrapped in the NHO. There were clinical signs of sciatic nerve lesion in 21.8% of cases (12 out of 55). ENMG showed signs of sciatic nerve lesions in only 55.6% (10 out of 18), only 4 of whom presented with clinical signs of a nerve lesion. No significant relationship was found between clinical symptoms and ENMG findings of sciatic nerve compression (n = 13, p = 0.77). CONCLUSION: Nerve compression by NHO is likely an underdiagnosed condition, particularly in patients who are unable to communicate. Diagnosis of sciatic compression by NHO should be based on regular clinical examinations and CT. ENMG is not sufficiently sensitive to be used alone for surgical decision-making.

Troublesome heterotopic ossification and stroke: Features and risk factors. A case control study.

PRIMARY OBJECTIVE: To determine the features of stroke-related HO in a large sample of patients and to assess if HO risk is increased by haemorrhagic stroke. RESEARCH DESIGN: A case control study (risk factor of a rare event using retrospective analysis). METHODS AND PROCEDURES: Sixty-one patients with stroke-81 troublesome HOs-were included, each was matched with four controls, i.e. 244 patients with no HO after stroke. Matching criteria were age (±3.5 years) and sex. Data recorded were time from stroke to surgery, ischaemic or haemorrhagic stroke and presence of HO risk factors. MAIN OUTCOMES AND RESULTS: Mean age at time of stroke = 46.02 ± 11.4 years (15.9-76.3) for the case sub-group. Time from stroke to surgery = 23.4 ± 27.8 months (3.6-150.0). There was a significant relationship between haemorrhagic stroke and HO development (OR = 3.01; 95% CI = 1.14-7.98; p < 0.05), but not for ischaemic stroke. This became non-significant when all matching and risk factors were included in the model (adjusted OR = 1.98; 95% CI = 0.60-6.54; p = 0.26). CONCLUSION: Haemorrhagic stroke appears to increase the risk of HO development. Further studies are required to determine if this risk factor is independent from other comorbid factors.

Patterns of post-acute health care utilization after a severe traumatic brain injury: Results from the PariS-TBI cohort.

OBJECTIVE: To assess brain injury services utilization and their determinants using Andersen's model. METHODS: Prospective follow-up of the PariS-TBI inception cohort. Out of 504 adults with severe traumatic brain injury (TBI), 245 survived and 147 received a 4-year outcome assessment (mean age 33 years, 80% men). Provision rates of medical, rehabilitation, social and re-entry services and their relations to patients' characteristics were assessed. RESULTS: Following acute care discharge, 78% of patients received physiotherapy, 61% speech/cognitive therapy, 50% occupational therapy, 41% psychological assistance, 63% specialized medical follow-up, 21% community re-entry assistance. Health-related need factors, in terms of TBI severity, were the main predictors of services. Provision of each therapy was significantly associated with corresponding speech, motor and psychological impairments. However, care provision did not depend on cognitive impairments and cognitive therapy was related to pre-disposing and geographical factors. Community re-entry assistance was provided to younger and more independent patients. CONCLUSIONS: These quantitative findings illustrate strengths and weaknesses of late brain injury care provision in urban France and highlight the need to improve treatment of cognitive impairments.

Ecological validity of the Dysexecutive Questionnaire: Results from the PariS-TBI study.

The Dysexecutive Questionnaire (DEX; Wilson, Pettigrew, & Teasdale, 1998 ) has been designed to assess executive dysfunctions in daily life. However, its relationships with cognitive testing, mood, and the ability to fulfil daily life demands, have not yet been systematically addressed. The objective of this study was to address these issues in a prospective four-year follow-up study of patients with severe traumatic brain injury (TBI) (PariS-TBI study). One hundred and forty seven patients were included. The DEX (self-version) showed a good internal consistency. The total DEX score was significantly inversely correlated with years of education, but did not significantly correlate with any initial injury severity measure. The DEX was significantly and positively related to cognitive deficits, as assessed with the Neurobehavioral Rating Scale-Revised (NRS-R); with mood disorders, as assessed with the Hospital Anxiety and Depression Scale (HADS); with dependency in elementary and extended activities of daily living; and with non-return to work. In multivariate analyses, cognitive and mood impairments were significantly and independently related to the total DEX score. These results suggest that the DEX is a multidetermined sensitive questionnaire to detect everyday life difficulties in patients with severe TBI at a chronic stage.

Occurrence of adverse events in long-term intrathecal baclofen infusion: a 1-year follow-up study of 158 adults.

OBJECTIVE: To assess the frequency and types of adverse events (AEs) related to intrathecal baclofen (ITB) therapy in adults, and associated risk factors. DESIGN: A prospective, observational cohort study of adults followed up from January 1 to December 31, 2010. SETTING: A neurologic rehabilitation department in a university hospital. PARTICIPANTS: All consecutive adult subjects (N=158) receiving ITB via a pump, either implanted or followed up during the study period. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Frequency and type of AEs. RESULTS: In 2010, 158 subjects were followed up for ITB therapy, of whom 128 were implanted before 2010 (nonsurgical subjects), and 30 underwent implantation in 2010 (surgical subjects). Of these 30 subjects, 20 were "newly implanted" and 10 were "replacements." The most frequent pathologic disorders were spinal cord injury (42%) and multiple sclerosis (28%). Twenty-eight subjects (18%) experienced a total of 38 AEs. The rate of AEs was .023 per month of ITB treatment. AEs were related to the surgical procedure in 53% of cases, to the device in 29% (predominantly catheter dysfunctions), and to adverse effects of baclofen in 18%. AEs related to the surgical incision (scar complications and collections) were more frequent in replacement than newly implanted subjects (P=.009). No significant association between occurrence of an AE and subject characteristics (age, gait capacity, spinal vs cerebral spasticity, duration of ITB therapy follow-up) was found. Nearly half of the AEs were serious, extending admission time by a mean of 16 days. No AE induced long-term morbidity or death. CONCLUSIONS: The AE rate was relatively low in this cohort. This has to be balanced against the clinical, functional, and quality-of-life improvements, which are expected from ITB therapy.

Determinants of satisfaction 1 year after total hip arthroplasty: the role of expectations fulfilment.

BACKGROUND: Between 7% and 15% of patients are dissatisfied after total hip arthroplasty (THA). To assess predictors and postoperative determinants of satisfaction and expectation fulfilment one year after (THA). METHODS: Before THA surgery, 132 patients from three tertiary care centres and their surgeons were interviewed to assess their expectations using the Hospital for Special Surgery Total Hip Replacement Expectations Survey (THR survey). One year after surgery, patients (n = 123) were contacted by phone to complete a questionnaire on expectation fulfilment (THR survey), satisfaction, functional outcome (Womac), and health-related quality of life (SF 12). Univariate and multivariate analyses were performed. RESULTS: Preoperative predictors of satisfaction were a good mental wellbeing (adjusted OR 1.09 [1.02; 1.16], p = 0.01) and optimistic surgeons expectations (1.07 [1.01; 1.14], p = 0.02). The main postoperative determinant of satisfaction was the fulfilment of patient's expectations (1.08 [1.04; 1.12], p < 0.001). Expectation fulfilment could be predicted before surgery by young age (regression coefficient -0.55 [-0.88; -0.21], p = 0.002), good physical function (-0.96 [-1.82; -0.10], p = 0.03) and good mental wellbeing (0.56 [0.14; 0.99], p = 0.01). Postoperative determinants of expectation fulfilment were functional outcome (-2.10 [-2.79; -1.42], p <0.001) and pain relief (-14.83 [-22.38; -7.29], p < 0.001). CONCLUSION: To improve patient satisfaction after THA, patients' expectations and their fulfilment need to be carefully addressed. Patients with low mental wellbeing or physical function should be identified and specifically informed on expected surgical outcome. Surgeons' expectations are predictive of satisfaction and information should aim to lower discrepancy between surgeons' and patients' expectations.

Predictors of informal care burden 1 year after a severe traumatic brain injury: results from the PariS-TBI study.

OBJECTIVE: To investigate predictors of informal care burden 1 year after a severe traumatic brain injury (TBI). PARTICIPANTS: Patients (N = 66) aged 15 years or older with severe TBI (Glasgow Coma Scale score of 8 or less) and their primary informal caregivers. SETTING: Multicenter inception cohort study over 22 months in Paris and the surrounding area (PariS-TBI study). MAIN MEASURES: Patients' preinjury characteristics; injury severity data; outcome measures at discharge from intensive care and 1 year after the injury; Dysexecutive Questionnaire; Medical Outcome Study Short Form-36; Zarit Burden Inventory. RESULTS: Among the 257 survivors at discharge from acute care, 66 patient-caregiver couples were included. Primary informal caregivers were predominantly women (73%), of middle age (age, 50 years), supporting male patients (79%), of mean age of 38 years. The majority (56%) of caregivers experienced significant burden, and 44% were at risk of depression. Caregivers' impaired health status and perceived burden significantly correlated with patients' global disability (as assessed with the Glasgow Outcome Scale-Extended) and impairments of executive functions (as assessed with the Dysexecutive Questionnaire). A focused principal component analysis suggested that disability and executive dysfunctions were independent predictors of perceived burden, whereas demographics, injury severity, and Glasgow Outcome Scale at discharge from acute care did not significantly correlate with caregiver's burden. CONCLUSION: Global handicap and impairments of executive functions are independent significant predictors of caregiver burden 1 year after TBI.

Weight gain after childhood traumatic brain injury: a matter of concern.

AIM: The aim of the study was to assess weight changes after traumatic brain injury (TBI) in children and the factors influencing them. METHOD: We conducted a longitudinal observational study of children with TBI of mixed severity who were consecutively admitted to one rehabilitation department (39 children; 23 males, 16 females; median age 8y 7mo; 25th to 75th centiles 3y 7mo-11y 6mo). Weight and height before TBI were obtained from the children's records and were measured monthly for 1 year after TBI. Body mass index (BMI) and BMI z-scores were calculated, and pre-TBI values were compared with the final values using paired tests. Linear mixed-effect interaction models were used to assess the effect of various factors on z-score evolution. RESULTS: Z-score curves revealed early weight loss followed by a rapid increase in weight. The mean BMI gain over the period under study was 0.9 kg/m² (p < 0.001) and the mean z-score gain was 0.4 (p = 0.006). Six children had become overweight by the time of final assessment. Factors associated with a greater rate of increase in the post-TBI z-score were mobility restriction, male sex, and older age. Global pre- to post-TBI weight gain was significantly higher in males (z-score 0.7). Pituitary hormonal testing was available for 17 children at 3 months and for 27 at 1 year. Growth hormone deficiency was detected in one child. INTERPRETATION: Weight gain of children during the first year after TBI was rapid and excessive. Male sex was a risk factor for excessive weight gain.

Impact of the operative delay and the degree of neurologic sequelae on recurrence of excised heterotopic ossification in patients with traumatic brain injury.

The timing of surgery with regard to recurrence risk after neurologic heterotopic ossification (HO) excision is still debated. This study investigated the association between recurrence risk after HO excision in traumatic brain injury (TBI) patients and (1) the operative delay and (2) the degree of neurologic sequelae (Garland status). A case-control study was performed. Patients who developed troublesome HO requiring surgery after TBI with (case, n = 16) or without recurrence (control, n = 64) were retrospectively included. Other matching criteria were sex and age at the time of surgery (± 4 years). The median delay for first HO surgery was 13.7 months (interquartile range: 9.0-37.1) for the case group and 13.2 months (interquartile range: 7.8-30.0) for the control group. No significant link was found between recurrence and operative delay (P = .54), even after inclusion of all matching factors (P = .53), or Garland status (P = .81). The inclusion of Garland status into the model did not change this result (P = .64). After TBI, no link was found between HO operative delay and recurrence. In spite of a common notion of a relationship between initial severity of TBI and HO development, no link was found between HO recurrence risk and the severity of sequelae.