Five-year follow-up of persons with brain injury entering the French vocational and social rehabilitation programme UEROS: Return-to-work, life satisfaction, psychosocial and community integration.

BACKGROUND: Social and vocational reintegration of persons with brain injury is an important element in their rehabilitation. AIMS: To evaluate the 5-year outcome of persons with brain injury included in 2008 in the Aquitaine Unit for Evaluation, Training and Social and Vocational Counselling programme (UEROS). METHOD: 57 persons with brain injury were recruited from those who completed the 2008 UEROS programme. Five years later, an interview was done to assess family and vocational status, autonomy and life satisfaction. These results were compared with those from persons completing the 1997-1999 programme. RESULTS: The typical person entered the 2008 UEROS programme 6 years after a severe brain injury (42%) and was male, single and 35 years. At the 5-year follow-up, more persons lived with a partner (+23%) and lived in their own home (+21%). 47% were working vs 11% on entering the programme. Approximately half were satisfied or very satisfied with their quality of life. Having a job in 2013 was associated with a high education level, less cognitive sequelae, having a job in 2008 and no health condition. CONCLUSIONS: The UEROS programme is effective with regard to return-to-work and improvement of autonomy in persons with brain injury, irrespective of length of time from injury.

The evaluation of behavioural changes in brain-injured patients: SOFMER recommendations for clinical practice.

UNLABELLED: Behavioural changes are the main cause of difficulties in interpersonal relationships and social integration among traumatic brain injury (TBI) patients. The Société française de médecine physique et réadaptation (SOFMER) decided to develop recommendations for the treatment and care provision for these problem under the auspices of the French health authority, the Haute Autorité de la santé (HAS). Assessment of behaviour is essential to describe, understand and define situations, assess any change and suggest lines for intervention. The relationship of these behavioural changes with the brain lesion is likewise of crucial importance in legal and forensic expertise. AIMS: Using a literature review and expert opinions, the aim was to define the optimal conditions for the collection of data on behavioural changes in individuals having sustained brain trauma, to identify the situations in which they arise, to review the instruments available, and to suggest lines of intervention. METHODS: A literature search identified 981 articles, among which 122 on the target subject were selected and analysed in detail and confronted with the experience of professionals and user representatives. A first draft of the recommendations was produced by the working group, and then submitted to a review group for opinions and complements. RESULTS: The literature on this subject is heterogeneous, and presents low levels of evidence. No article enabled the development of recommendations above the "expert opinion" level. After prior clarification of the aims of the evaluation, it is recommended first to carefully describe the changes in behaviour, from patient and third-person narratives, and where possible from direct observations. The information enabling the description of the phenomena occurring should be collected by different individuals (multi-source evaluation): the patient, his or her close circle, and professionals with different training backgrounds (multidisciplinary evaluation). The analysis of triggering or associated factors requires an assessment of cognitive functions and any neurological pathology (seizures). After confrontation and synthesis, the information should be completed using one or several behavioural scales, which provide objectivity and reproducibility. The main generic and specific scales are presented, with their advantages, drawbacks and validation references. The group did not wish to recommend any one of them in particular. CONCLUSION: The evaluation of behavioural changes is essential, since without it a therapeutic strategy and appropriate orientation cannot be implemented. The emphasis should be put on contextualised, multi-source and multidisciplinary evaluation, including validated behavioural scales. In this area, nevertheless, evaluation is still restricted by several methodological limitations. Further research is needed to improve the standardisation of data collection and the psychometric properties of the instruments. A European harmonisation of these procedures is also greatly needed.

Cognitive and behavioural post-traumatic impairments: what is the specificity of a brain injury ? A study within the ESPARR cohort.

OBJECTIVE: The variety and extent of impairments occurring after traumatic brain injury vary according to the nature and severity of the lesions. In order to better understand their interactions and long-term outcome, we have studied and compared the cognitive and neurobehavioral profile one year post onset of patients with and without traumatic brain injury in a cohort of motor vehicle accident victims. METHOD: The study population is composed of 207 seriously injured persons from the ESPARR cohort. This cohort, which has been followed up in time, consists in 1168 motor vehicle accident victims (aged 16 years or more) with injuries with all degrees of severity. Inclusion criteria were: living in Rhone county, victim of a traffic accident having involved at least one wheel-conducted vehicle and having occurred in Rhone county, alive at the time of arrival in hospital and having presented in one of the different ER facilities of the county. The cohort's representativeness regarding social and geographic criteria and the specificities of the accidents were ensured by the specific targeting of recruitment. Deficits and impairments were assessed one year after the accident using the Neurobehavioral Rating Scale - Revised and the Trail-Making Test. Within our seriously injured group, based on the Glasgow Score, the presence of neurological deficits, aggravation of neurological condition in the first 72hours and/or abnormal cerebral imaging, we identified three categories: (i) moderate/severe traumatic brain injury (n=48), (ii) mild traumatic brain injury (n=89), and (iii) severely injured but without traumatic brain injury (n=70). RESULTS: The most frequently observed symptoms were anxiety, irritability, memory and attention impairments, depressive mood and emotional lability. While depressive mood and irritability were observed with similar frequency in all three groups, memory and attention impairments, anxiety and reduced initiative were more specific to traumatic brain injury whereas executive disorders were associated with moderate/severe traumatic brain injury. DISCUSSION-CONCLUSION: The presence and the initial severity of a traumatic brain injury condition the nature and frequency of residual effects after one year. Some impairments such as irritability, which is generally associated with traumatic brain injury, do not appear to be specific to this population, nor does depressive mood. Substantial interactions between cognitive, affective and neurobehavioral disorders have been highlighted.

Everyday-like memory and its cognitive correlates in healthy older adults and in young patients with traumatic brain injury: a pilot study based on virtual reality.

UNLABELLED: PURPOSE STATE: A pilot-study with a comparison approach between aging and traumatic brain injury (TBI) is proposed to investigate everyday object memory patterns using a virtual HOMES test. METHODS: Sixteen young controls, 15 older adults and 15 TBI patients underwent the HOMES test and traditional tests. RESULTS: Older adults and TBI patients exhibited similar HOMES performances: poor recall, a greater recognition benefit, high false recognitions, but intact clustering and proactive interference effects. The age-related differences for HOMES measures were mainly mediated by executive functioning, while the HOMES performances in the TBI group were correlated with memory measures. CONCLUSION: The differential cognitive mediating effects for a similar everyday-like memory pattern are discussed by highlighting the need for more cautious interpretations of cognitive mechanisms behind similar behavioral patterns in different populations especially in clinical and rehabilitation settings.

Participation restrictions in patients with psychiatric and/or cognitive disabilities: preliminary results for an ICF-derived assessment tool.

UNLABELLED: Participation in community life is a major challenge for most people with psychiatric and/or cognitive disabilities. Current assessments of participation lack a theoretical basis. However, the new International Classification of Functioning, Disability and Health (ICF) provides a relevant framework. AIMS: The present study used an ICF-derived assessment tool to activity limitations and participation restrictions in two groups of participants with disabilities linked to schizophrenia or traumatic brain injury respectively. METHODS: Twenty-six items (related to six ICF sections) were selected by reviewing the literature and gathering the clinician's opinions and representatives of patient associations. These items, yielded an ordinal rating of activity limitations, participation restrictions and contextual factors (social support, attitudes and, systems & politics). Special attention was paid to contextual and environmental factors. The final checklist (called the Grid for Measurements of Activity and Participation, G-MAP) was administered to 16 participants with traumatic brain injury (the TBI group) and 15 participants with schizophrenic disorders (the SD group). Psychometric assessments of cognition and, neurobehavioural, psychological and psychosocial functioning were also performed. RESULTS: The internal consistencies for activity limitations (Cronbach's alpha coefficient=0.89) and participation restriction (Cronbach's alpha coefficient=0.89) were satisfactory. We did not observe any significant differences between the two groups in terms of the psychometric test results. The G-MAP scores demonstrated that the two groups were confronted with the same limitations in self care, domestic life, leisure and community life (i.e., the intergroup differences were not statistically significant in Mann-Whitney tests). However, interpersonal relationships and economic and social productivity appeared to be more severely limited in the SD group than in the TBI group. Similarly, participation restrictions in domestic life, interpersonal relationships and economic and social productivity were more severe in the SD group than in the TBI group. CONCLUSION: G-MAP is a useful, feasible, relevant tool for performing a detailed, individualized assessment of participation restrictions in people with psychiatric and/or cognitive disabilities.

Inter-observer reproducibility of back surface topography parameters allowing assessment of scoliotic thoracic gibbosity and comparison with two standard postures.

The objective of this work was to analyze the inter-observer reproducibility of an upright posture designed to bring out the thoracic humps by folding the upper limbs. The effect of this posture on back surface parameters was also compared with two standard radiological postures. A back surface topography was performed on 46 patients (40 girls and 6 boys) with a minimum of 15° Cobb angle on coronal spinal radiographs. Inter-observer reliability was evaluated using the typical error measurement (TEM) and Intraclass Correlation Coefficient (ICC). Variations between postures were assessed using a Student's t test. The inter-observer reproducibility is good enough for the three postures. The proposed posture leads to significant changes in the sagittal plane as well as in the identification of thoracic humps. This study shows the reproducibility of the proposed posture in order to explore the thoracic humps and highlights its relevance to explore scoliosis with back surface topography systems.

Percutaneous treatment of sciatica caused by a herniated disc: an exploratory study on the use of gaseous discography and Discogel(®) in 79 patients.

OBJECTIVES: Sciatica is a common disease; between 13% and 40% of the general population will experience at least one episode of sciatica due to spinal disc herniation and nerve root irritation. In some specialist centres, percutaneous intradiscal techniques can be applied as an intermediate measure between conservative treatment and surgery, with a view to avoiding the adverse events associated with surgical discectomy. Discogel(®) is a percutaneously implanted medical device for the treatment of lumbar sciatica due to a herniated disc. We performed an open, prospective, observational study in order to (a) determine whether the prior use of air disc manometry could limit the risk of nerve root irritation reportedly associated with nucleolysis and administration of Discogel(®) and (b) investigate the technique's efficacy and safety. METHOD: A total of 79 Discogel(®)-treated patients were systematically reviewed. A nurse anaesthetist evaluated each patient's pain levels during the procedure itself. The therapist assessed the patient on inclusion and 8weeks after the Discogel(®) procedure. A third assessment was based on a telephone interview (by an independent assessor) at least 4months after the procedure. RESULTS: Pain levels immediately after the Discogel(®) procedure (1.7±2.0) were markedly lower than before the procedure (5.5±2.3). There were no complications. Two months after Discogel(®) administration, the initial pain level had fallen by an average of 74±34%. The outcome was quite stable over time (mean follow-up: 8months). At the end of the follow-up period, 60.7% of the patients were free of pain, 76% considered the treatment outcome to be good or very good, 74% had returned to work and 76% would recommend the treatment to a friend. CONCLUSION: The favourable outcomes associated with the procedure should now be confirmed in a controlled trial.

Physical and rehabilitation medicine (PRM) care pathways: adults with severe traumatic brain injury.

This document is part of a series of guidelines documents designed by the French Physical and Rehabilitation Medicine Society (SOFMER) and the French Federation of PRM (FEDMER). These reference documents focus on a particular pathology (here patients with severe TBI). They describe for each given pathology patients' clinical and social needs, PRM care objectives and necessary human and material resources of the pathology-dedicated pathway. 'Care pathways in PRM' is therefore a short document designed to enable readers (physician, decision-maker, administrator, lawyer, finance manager) to have a global understanding of available therapeutic care structures, organization and economic needs for patients' optimal care and follow-up. After a severe traumatic brain injury, patients might be divided into three categories according to impairment's severity, to early outcomes in the intensive care unit and to functional prognosis. Each category is considered in line with six identical parameters used in the International Classification of Functioning, Disability and Health (World Health Organization), focusing thereafter on personal and environmental factors liable to affect the patients' needs.

Psychotherapeutic follow up of out patients with traumatic brain injury: preliminary results of an individual neurosystemic approach.

UNLABELLED: Psychotherapy for affective/behaviour disorders after traumatic brain injury (TBI) remains complex and controversial. The neuro-systemic approach aims at broadening the scope in order to look at behaviour impairments in context of both patient's cognitive impairments and family dysfunctioning. OBJECTIVE: To report a preliminary report of a neuro-systemic psychotherapy for patients with TBI. PATIENTS AND METHODS: All patients with affective/behaviour disorders referred to the same physician experienced in the neuro-systemic approach were consecutively included from 2003 to 2007. We performed a retrospective analysis of an at least 1-year psychotherapy regarding the evolution of the following symptoms: depressive mood, anxiety, bipolar impairment, psychosis, hostility, apathy, loss of control, and addictive behaviours as defined by the DSM IV. Results were considered very good when all impairments resolved, good when at least one symptom resolved, medium when at least one symptom improved, and bad when no improvement occurred, or the patient stopped the therapy by himself. RESULTS: Forty-seven patients, 35 men and 12 women, with a mean age of 33.4 years, were included. Most suffered a severe TBI (mean Glasgow coma score: 6.4) 11 years on average before the inclusion. At the date of the study, 11 patients (23%) had a poor outcome, 23 (48%) suffered Moderate disability and 13 (27%) had a Good recovery on the GOS scale. All therapy sessions were performed by the same physician, with 10 sessions on average during 13.5 months. Results were classified very good in six cases (13%), good in 18 others (38%), medium in 10 patients (21%) and bad in 13 cases (27%). We observed a significant improvement of affective disorders, namely anxiety (P<0.001) depressive mood (P<0.001) and hostility (P<0.01). However, bipolar symptomatology, apathy, loss of control and addictive disorders did not improve. DISCUSSION/CONCLUSION: From our best knowledge, this is the first clinical report of neuro-systemic psychotherapy for affective/behaviour disturbances in TBI patients. This kind of therapy was shown to be feasible, with a high rate of compliance (72%). Psycho-affective disorders and hostility were shown to be more sensitive to therapy than other behaviour impairments. These preliminary findings have to be confirmed by prospective trials on broader samples of patients.

Assessment of quality of life in stroke patients with hemiplegia.

UNLABELLED: Stroke is a major public health issue. Even though most hemiplegic stroke patients may obtain a good functional outcome, many remain dissatisfied with their lives. Indeed, quality of life and subjective well-being should be taken into account in any assessment of stroke survival. OBJECTIVE: To assess long-term quality of life in stroke patients (compared with healthy controls) and the corresponding determinants and predictive factors. METHOD: The patient population consisted of 80 of the 217 first-stroke survivors treated between January and June 2005 in the Clinical Neurosciences Department at Bordeaux University Hospital. After a mean follow-up period of 2 years, 24 patients were interviewed in their homes and data from the 56 others were obtained in a telephone interview. Demographic information, clinical status on admission and functional status (as assessed by Barthel Index) and depression (on the ADRS) at the time of the study visit were recorded. Quality of life was assessed by using the Sickness Impact Profile (SIP-65) and Bränholm and Fugl-Meyer's Satisfaction with Life Scale (LiSat 11). The patients' data were compared with those from 149 healthy controls. RESULTS: Life satisfaction and quality of life were significantly impaired in stroke patients, compared with controls. All life domains were impaired. The worst scores were observed for independence and health-related items in the LiSat 11 and the physical and communication items in the SIP-65. Quality of life was strongly correlated with functional independence, the persistence of hemiplegia and depressive mood, which is in agreement with literature findings. Neither gender nor the initial Rankin score had a significant impact on these parameters. DISCUSSION-CONCLUSION: Quality of life at 2 years is significantly impaired in stroke survivors and seems more difficult to predict than functional independence. However, in addition to these objective results, our interviews suggest that receiving adequate social support might be as important to patients as recovering independence.

Stroke in under-75-year-olds: expectations, concerns and needs.

UNLABELLED: Most studies of functional outcomes in hemiplegic stroke patients use standard disability rating scales (such as the Barthel Index). However, planning the allocation of assistance and resources requires additional information about these patients' expectations and needs. AIMS OF THE STUDY: To assess functional independence in daily living and house holding, changes in home settings, type of technical aid and human helps, and expectations in hemiplegic patients 1 to 2 years after the stroke. METHODS: Sixty-one out of 94 patients admitted to the neurovascular unit of French university hospital for a first-ever documented stroke were consecutively enrolled. The study was restricted to patients under 75, since patients over 75 do not follow the same care network. Patients were examined at their homes or interviewed by phone 17 months (on average) after the stroke. Standard functional assessment tools (such as the Barthel Index and the instrumental activities of daily living [IADL] score) were recorded, along with descriptions of home settings and instrumental and human help. Lastly, patients and caregivers were asked to state their expectations and needs. RESULTS: Although only one person was living in a nursing home after the stroke, 23 (34%) of the other interviewees had needed to make home adjustments or move home. Seven patients (11%) were dependent in terms of the activities of daily living (a Barthel Index below 60) and 11 (18%) had difficulty in maintaining domestic activities and community living (an IADL score over 10). Although the remaining patients had made a good functional recovery, 23 were using technical aids and 28 needed family or caregiver assistance, including 23 patients with full functional independence scores. Twenty-five patients (42%) were suffering from depression as defined by the diagnosis and statistical manual of mental disorders (4th edition, text revision, DSM IV-R). The patients' prime concerns were related to recovery of independence, leisure activities and financial resources. Family members' expectations related to the complexity of administrative matters, lack of information and the delay in service delivery. DISCUSSION AND CONCLUSION: In under-75 hemiplegic stroke patients, high scores on standard disability rating scales do not always mean that no help is required.

Is there a link between alertness and fatigue in patients with traumatic brain injury?

OBJECTIVES: Many patients with traumatic brain injury (TBI) report chronic fatigue, and previous studies showed a potential relationship between sleepiness and fatigue in these patients. Our study first looked at the impact of objective and subjective sleepiness on fatigue in patients with TBI. We then investigated how fatigue could affect driving performance in these patients. METHODS: Nocturnal polysomnography, the Fatigue Severity Scale (FSS), the Epworth Sleepiness Scale (ESS), and five 40-minute maintenance of wakefulness tests (MWT) were collected in 36 patients with TBI. Fitness to drive was assessed in a subsample of 22 patients compared to 22 matched controls during an hour simulated driving session. RESULTS: In patients with TBI, FSS, ESS, and mean MWT scores (+/-SD) were 27 +/- 10, 8 +/- 4, and 35 +/- 7 minutes vs 15 +/- 2.5, 5 +/- 3, and 37 +/- 5 minutes in controls. Patients with TBI reported more chronic fatigue (W = 99, p < 0.001) than controls, and, unlike in controls, the level of chronic fatigue was correlated to their MWT scores. Patients' driving performances were worse than the controls' (W = 79, p < 0.001). The best predictive factors of driving performance were fatigue scores and body mass index (multiple R = 0.458, 41.8% of explained variance). CONCLUSION: In patients with TBI, chronic fatigue is significantly related to subjective and objective levels of alertness, even though these levels are not highly pathologic. This might suggest that a small level of sleepiness (i.e., MWT scores between 33 and 39 minutes) worsens fatigue in these patients. Chronic fatigue and body mass index could predict driving simulator performance in patients with TBI.

Second language acquisition after traumatic brain injury: a case study.

BACKGROUND: Post-traumatic language and memory impairment, as well as a subsequent recovery in monolinguals have been widely documented in the literature, yet little is known about learning the second language after a severe head trauma followed by coma, as well as the relationship of this process with cognitive recovery, psychological status and quality of life. PURPOSE: The present study investigates the relationship of learning the second language (English) in the process of rehabilitation, with quality of life in a Polish female university student who, as a result of a car accident, suffered a major closed-head injury and was comatose for a month. METHOD: The subject was enrolled in an English learning program nine months after the trauma. The experiment lasted six months and comprised monthly meetings. RESULTS: The patient improved the major components of the second language, including vocabulary. Within the 6 months, the subject was gradually capable of learning additional and more complex lexical items. DISCUSSION: Learning the second language after traumatic brain injury may positively influence emotional well-being, self-esteem, and, perhaps, recovery of quality of life. A long-term beneficial effect of learning L2 was a consequential improvement of the patient's memory.

[Intrathecal baclofen in hereditary spastic paraparesis: benefits and limitations]. / Intérêts et limites du baclofène intrathécal dans les paraparésies spastiques héréditaires.

BACKGROUND: Chronic intrathecal delivery of baclofen has been introduced for treatment of severe spinal spasticity. Very little is known about this treatment in hereditary spastic paraparesis. Here we review the benefits and limitations of pump implantation for baclofen delivery in this population. METHODS: Consecutive patients presenting with hereditary spastic paraparesis were assessed for spasticity (Ashworth and Penn scores), muscular strength and walking (speed, comfort and perimeter length). The effect of intrathecal delivery of baclofen was judged after progressive bolus injections or chronic administration by electrical syringe. The pump implantation was proposed when spasticity scores decreased by 2 or more points, with muscular strength preserved and walking area increased. RESULTS: We investigated 6 patients (3 males; mean age 48 years) with hereditary spastic paraparesis. The mean follow-up was 19 years; for 4 patients who received pump implantation, the mean follow-up was 6.2 years. The mean baclofen daily dose was 75 mug. Satisfaction was high for patients who received implantation early instead of waiting for the natural course of the disease. DISCUSSION: Some patients with hereditary spastic paraparesis have good functional improvement with chronic intrathecal delivery of baclofen if walking is still possible. Despite the natural history of the disease, functional results are stable during the first 5 years of treatment. The data indicate a possible compromise between decreased spasticity and muscular strengthening with the treatment.

[Outcome of the Aquitaine Unit for Evaluation, Training and Social and Vocational Counselling (UEROS) at 5-year follow-up in young adults with brain damage]. / Programme d'aide à la réinsertion sociale et professionnelle de jeunes adultes cérébrolésés: résultats à cinq ans du réseau UEROS-Aquitaine.

INTRODUCTION: Difficulties in social and vocational adjustment are common in adults with brain damage. A French government-funded program, UEROS (Unit for Evaluation, Training and Social and Vocational Counselling), was developed to improve cognitive adjustment, social autonomy and return to work for these people. OBJECTIVES: To describe the outcome and satisfaction with life after 5 years for patients who participated in the UEROS-Aquitaine network program. MAIN OUTCOME MEASURES: EBIS Document to evaluate people with traumatic brain injury. RESULTS: Seventy-five of the 102 patients participating in UEROS from 1997 to 1999 were assessed during a phone-structured interview based on the EBIS Document. The sample consisted of young adults (mean age 28.5 years), most (65, 85%) with brain injury and moderate disability (Glasgow Outcome Scale 2: 57%) or severe disability (Glasgow Outcome Scale 3: 42%). On entering the program, 33% of the subjects needed no help physically or cognitively. None were employed. At the end of the program, 9% were students or were learning a job, 8% worked full-time, 16% were in sheltered conditions, and 13% had volunteer activities. At 5-year follow-up, 50% of the subjects were independent, 4% were in school, 10.6% worked full-time, and 26.7% were in sheltered conditions. Playing sports was associated with good social adjustment. The professional status at 5 years was significantly correlated with following the UEROS program (r=0.30, P<0.01) and status at the end of the program (r=0.29, P<0.05). However, 41.3% of the subjects were still unsatisfied with their conditions of life. DISCUSSION-CONCLUSION: In patients with brain damage, the UEROS-Aquitaine network program improves independence in daily living and allows for nearly one inactive adult in two (42%) to be engaged in an activity or a job.

[Neuropsychology and forensic assessment in brain injured patients]. / Neuropsychologie: son apport dans l'expertise des traumatisés crâniens adultes.

Neuropsychology, which deals with the relationships between upper mental functions and brain structures is directly involved with psychiatric and psychological disorders and thus constitutes one of the major domains of cognitive sciences. The impairment of upper mental functions is evident after severe brain injuries causing significant motor deficits. However, it is becoming increasingly evident that even mild or moderate brain injuries can cause sequelae which are difficult to analyze and quantify clinically. These sequelae constitute an "invisible handicap" which may greatly interfere with the patient's professional, relational and social life. The neuropsychological evaluation must be systematic and complete and has to be carried out with a sufficient hindsight (two to three years after the trauma) using neuropsychological and behavioural deficiency evaluation scales. Psychometric tests are also necessary. The data obtained from this evaluation must be correctly interpreted and constitutes the main exhibit in the forensic examination of the brain injured patient.

[The neurobehavioral rating scale-revised: assessment of concurrent validity]. / Echelle neurocomportementale révisée: étude de la validité concourante.

UNLABELLED: Cognitive and behavioral impairment are a major source of disability in daily living of patients with traumatic brain injury (TBI). The Neurobehavioral Rating Scale-Revised (NRS-R) is a short, easy-to administer interview tool developed to improve assessment by clinicians. Data are available on its criterion validity and reliability, but the concurrent validity of the French NRS-R was not yet documented. OBJECTIVE: To assess the concurrent validity of the NRS-R with current psychometric tests. METHOD: One hundred and four patients with TBI enrolled in a community adjustment program underwent concurrent examination with the NRS-R, cognitive tests assessing memory, attention, and executive functions, and scales of anxiety (STAI) and depressive mood (CES-D). Intercorrelations were undertaken between these variables and the five factors of the NRS-R: F1, intentional behavior; F2, lowered emotional state; F3, survival-oriented behaviour/hightened emotional state; F4, arousal state; and F5, language. Patients were 82 men and 22 women, the mean age was 28.5 years, and 70% had severe TBI (Glasgow coma score [GCS] below 8 on admission). They were assessed 52 months on average after their injury. RESULTS: Factor F1 was correlated with results on the GCS (P<0.05), the Tower of London test (TL, P<0.01), the Trail Making Test (TMT, P<0.01), divided attention (DA) and inhibition (IN) subscales of the Zimmermann and Fimm's Attention battery (TEA) (P<0.01) and reverse digit span (DS, P<0.05). Factor F2 was positively related to age at injury, time since injury (TSI) (P<0.05) and CESD and STAI scores (P<0.001). Factor F3 was related to DA (P<0.01) TL scores and TSI (P<0.05). Factor F4 was related to TL, TMT, DA, flexibility, DS (P<0.05), TSI, duration of post-traumatic amnesia, CES-D score (P<0.05) and STAI scores (P<0.01). Factor F5 was related to GCS, DA (P<0.05), and reaction time on the subscales IN and Go/nogo (GO) of the TEA battery (P<0.01). The NRS-R total score was related to CESD, STAI scores, TMT score, DA (P<0.01) and TL score, IN and GO scores and TSI (P<0.05). DISCUSSION: As McCauley et al found with the English version of the NRS-R, significant relationships were found between NRS-R factor scores, cognitive tests and emotional scales. Relationships were also found between factor scores and indicators of injury severity and time since injury. These data suggest fair concurrent validity of the NRS-R.

[Non verbal communication abilities in severe traumatic brain injury]. / Compétences de communication non verbale des traumatisés crâniens graves.

OBJECTIVE: Discursive abilities of severe brain injured patient are always impaired: loss of flexibility, lack of cohesion and coherence, often more elliptic. We know few about nonverbal competencies during discourse. The objective is to verify nonverbal abilities of these patients by pragmatic analysis. METHODS: Four men were examined more than 7 years after severe traumatic brain injury. Nonverbal Prutting and Kirchner Pragmatic Protocol (1987) were done allowing to a qualitative and quantitative measurement of paralinguistic behaviour: prosody and quality of speech, facial expression, posture, gaze, gesture. Two conditions were recorded: dual (descriptive discourse) and group (conversational discourse). Associated impairments such as cognitive and dysexecutive functioning were also investigated. RESULTS/DISCUSSION: Impoverishment (loss of ability) or impaired inadequacity was observed in all patients. Paralinguistic competences of conversational discourse was worse than descriptive one. Facial expression, gaze functioning, referential gesture were more often impaired. Maladjustment could be interpretated in reference with dysexecutive syndrome. CONCLUSION: In spite of the lack of information about the range of normal pragmatic behaviour, it seems that brain injured patients have shown poor nonverbal abilities during discourse. Rehabilitation training of communication skills would integrate this fact in order to improve interactivity and social relationship.