Guidelines for Quality Management of Apallic Syndrome / Vegetative State.

INTRODUCTION: Epidemiology in Europe shows constantly increasing figures for the apallic syndrome (AS)/vegetative state (VS) as a consequence of advanced rescue, emergency services, intensive care treatment after acute brain damage and high-standard activating home nursing for completely dependent end-stage cases secondary to progressive neurological disease. Management of patients in irreversible permanent AS/VS has been the subject of sustained scientific and moral-legal debate over the past decade. METHODS: A task force on guidelines for quality management of AS/VS was set up under the auspices of the Scientific Panel Neurotraumatology of the European Federation of Neurological Societies to address key issues relating to AS/VS prevalence and quality management. Collection and analysis of scientific data on class II (III) evidence from the literature and recommendations based on the best practice as resulting from the task force members' expertise are in accordance with EFNS Guidance regulations. FINDINGS: The overall incidence of new AS/VS full stage cases all etiology is 0.5-2/100.000 population per year. About one third are traumatic and two thirds non traumatic cases. Increasing figures for hypoxic brain damage and progressive neurological disease have been noticed. The main conceptual criticism is based on the assessment and diagnosis of all different AS/VS stages based solely on behavioural findings without knowing the exact or uniform pathogenesis or neuropathological findings and the uncertainty of clinical assessment due to varying inclusion criteria. No special diagnostics, no specific medical management can be recommended for class II or III AS treatment and rehabilitation. This is why sine qua non diagnostics of the clinical features and appropriate treatment of AS/VS patients of "AS full, remission, defect and end stages" require further professional training and expertise for doctors and rehabilitation personnel. INTERPRETATION: Management of AS aims at the social reintegration of patients or has to guarantee humanistic active nursing if treatment fails. Outcome depends on the cause and duration of AS/VS as well as patient's age. There is no single AS/VS specific laboratory investigation, no specific regimen or stimulating intervention to be recommended for improving higher cerebral functioning. Quality management requires at least 3 years of advanced training and permanent education to gain approval of qualification for AS/VS treatment and expertise. Sine qua non areas covering AS/VS institutions for early and long-term rehabilitation are required on a population base (prevalence of 2/100.000/year) to quicken functional restoration and to prevent or treat complications. Caring homes are needed for respectful humane nursing including basal sensor-motor stimulating techniques. Passive euthanasia is considered an act of mercy by physicians in terms of withholding treatment; however, ethical and legal issues with regard to withdrawal of nutrition and hydration and end of life discussions raise deep concerns. The aim of the guideline is to provide management guidance (on the best medical evidence class II and III or task force expertise) for neurologists, neurosurgeons, other physicians working with AS/VS patients, neurorehabilitation personnel, patients, next-of-kin, and health authorities.

Sensorimotor recovery in children after traumatic brain injury: analyses of gait, gross motor, and fine motor skills.

The recovery of gait, gross motor proficiency, and hand function was examined in 23 children (13 males, 10 females; age 4 years 7 months to 15 years 10 months) with traumatic brain injury (TBI) over five months of in patient rehabilitation. We used gait analysis, the Gross Motor Function Measure, the Developmental Hand Function Test, and the Purdue Pegboard test. Brain injury had been severe (initial Glasgow Coma Scale GCS <8) in 17 children and moderate (GCS 8-10) in six children. Compared with healthy control children of the same age and sex, repeated gait analyses in ambulatory children with brain injury showed significant reductions of velocity, stride length and cadence, and impaired balance. Spatiotemporal gait variables were correlated with Gross Motor Function Measure scores. Hand function tests revealed deficits in fine motor skills, speed, and coordination. Degree of impairment increased with trauma severity. Despite significant improvements, differences in gait velocity, stride length, and hand function of children with brain injuries and controls were still present about 8 months after TBI. Hand motor skills improved less than gait. Young age at injury was not associated with better recovery.

Recovery of spatial memory and persistence of spatial orientation deficits after traumatic brain injury during childhood.

The present study set out to examine the recovery of spatial learning and cognitive mapping skills after severe TBI in childhood. A prospective investigation was carried out with repeated measures. Children with TBI (n = 18) and healthy matched controls (n = 18) were investigated while the children with TBI stayed in a rehabilitation facility (t0) and 4 years later (t1). Children were assessed with the Kiel Locomotor Maze, where they had to remember defined locations in an experimental chamber with completely controlled intra- and extra-maze cues until the learning criterion was reached. During probe trials, cognitive mapping strategies were assessed. Results showed (i) that spatial learning is functionally restituted 4 years post-trauma and (ii) that cognitive mapping skills are still impaired 4 years post-trauma. It was concluded that cognitive performance of children who survived a severe TBI may he overestimated, having far reaching consequences for the children.

Analyses of gait, reaching, and grasping in children after traumatic brain injury.

OBJECTIVE: To evaluate motor behavior in children after traumatic brain injury (TBI) with quantitative instrumented measures of gait and of functional hand movements (reaching, grasping) and with clinical assessments. DESIGN: Case-control study. SETTING: Tertiary pediatric trauma rehabilitation center in Germany. PARTICIPANTS: Twenty children (age range, 6-13 y) with moderate or severe TBI were examined 1+/-1.2 years (mean +/- standard deviation) postinjury. Fifteen were reexamined 2 months later. Control data were obtained from 20 healthy children and matched for age, gender, and school grade. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Quantitative measures included 10 spatiotemporal gait parameters and 6 variables describing reaching and grasping. Qualitative scores of gait and upper-limb movements were also obtained. RESULTS: Gait velocity and step and stride lengths were significantly smaller in children after TBI than in control subjects (Mann-Whitney U test, P<.05). Reach-to-grasp movements of the TBI children were characterized by a significantly longer reaction time (Mann-Whitney U test, P<.05) and movement duration, reduced velocity, and coordination deficits. The instrumented measures did not change significantly in 2 months. Several significant correlations between clinical and instrumented measures were obtained. CONCLUSION: Functional motor behavior is affected in children after moderate or severe TBI. To supplement clinical assessments with objective data, impairments of gait, reaching, and grasping movements can be recorded with instrumented measures.

Influence of age-related factors on long-term outcome after traumatic brain injury (TBI) in children: A review of recent literature and some preliminary findings.

Cerebral plasticity of the immature brain is often inferred to lead to less serious consequences of early traumatic brain injury (TBI) in the pediatric age group. This notion is seriously challenged by recent research findings. Data from prospective studies point to some children's dif-ficulties in ongoing skill-acquisition and the possibility of late-emerging deficits. Accordingly, preliminary group data of an own ongoing study support the notion of an increased risk for pervasive neuropsychological impairment in subjects with severe TBI and early age at trauma. The pattern of neuropsychological deficits may depend on the developmental level at the time of injury, although effects of hemispheric site of lesion were also found to persist in individual cases. Theoretical considerations and empirical findings stress the importance of a longitudinal developmental perspective for the evaluation of long-term outcome after pediatric TBI. ("Verbund Neurotrauma Kiel / Project 4: Evaluation of neurological rehabilitation and course of cognitive development in children and adoles-cents with secondarily acquired brain damage", funded through the Research Program "Gesundheit 2000" of the German government, FKZ 01 KO 9512.)

Assessment of sensorimotor functions after traumatic brain injury (TBI) in childhood - Methodological aspects.

Various basic qualitative and quantitative methods for the evaluation of sensorimotor functions after Traumatic Brain Injury (TBI) are introduced and discussed. Methodological aspects are illustrated by a single case follow-up study of a child after severe TBI (age 11; 7-12;1 yrs; 6, 8 and 12 month post TBI) in comparison to an age-matched healthy control group (N=16). The evaluation consisted of neurological investigation, Barthel-Index, Terver Numeric Score for Functional Assessment, Rappaport Disability Rating Scale (modified version), a coordination-test for children (KTK), a pilot-tested Motor Function Score, quantitative evaluation of spatiotemporal gait parameters on a walkway and on a treadmill, and the kinematic assessment of hand motor functions. Quantitative movement analyses revealed two general types of motor disorder: Slowing of movements and compensatory motor strategies. Averaged z-scores showed deficits, which were pronounced in fine motor skills (hand movements: 1.86, gait: 1.3). During follow-up, a strong improvement rate during the first (-0.48 z-scores) and nearly no improvement rate (-0.03 z-scores) during the second time interval was seen. Clinical scores and developmental tests were not able to document the whole restitutional course, whereas motor tests with special emphasis on functional aspects and the quantitative movement assessment seemed to be suitable methods. We conclude that a sufficient evaluation of sensorimotor functions after TBI in childhood needs an increase in procedural uniformity on onehand and the combination of various qualitative and quantitative methods on the other hand. To connect both claims, further research is necessary.