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.

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.

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.

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.

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.

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.

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.

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.

Role of the physical and rehabilitation medicine specialist regarding of children and adolescents with acquired brain injury.

Acquired brain injury (ABI) is one of the most common causes of mortality and severe disability in children and adolescents. Those with ABI may suffer any of a wide range of disorders that may limit their activity, their participation in family and school life, and their involvement in society in general. This paper describes the different stages of recovery - hospitalisation, preparing for discharge, and long term follow-up, in which PRM specialists are involved. Although the involvement of the PRM specialist is important in all three stages, it is during the latter two stages when his or her expertise is particularly important. An interdisciplinary care team - which the PRM specialist is well placed to lead ­ is required if the best results are to be achieved.

Executive functions of children with developmental dyspraxia: assessment combining neuropsychological and ecological tests.

OBJECTIVE: To assess executive function in children with developmental dyspraxia. INCLUSION CRITERIA: children aged 8 years to 12 years 5 months at the time of the study, diagnosed with developmental dyspraxia between January, 2008 and August, 2009 by a multidisciplinary team in one single center. ASSESSMENT TOOLS: (1) Paper-and-pencil neuropsychological and ecological tests to assess flexibility, planning, inhibition and prospective memory; (2) two questionnaires answered by parents; (3) the 'Children's Cooking Task' (CCT), an ecological task performed in a real environment (Chevignard et al., 2009 [15]). In this last test, children were compared to matched controls. Non-parametric statistical tests were used. RESULTS: Thirteen patients participated in the study (11 boys-2 girls; mean age 10.3 years [SD=1.3]). Neuropsychological tests highlighted planning and inhibition disorders, but no impaired flexibility. For more than half of the children, the questionnaires indicated impaired executive functions in daily life tasks. Finally, patients showed a significantly increased rate of errors during the CCT, compared with the control group (P<0.001). CONCLUSION: Overall results suggest that some children diagnosed with developmental dyspraxia also exhibit executive function disorders. Ecological tests seem more sensitive for identifying executive function disorders than conventional tests.

[Outcome after a shaken baby syndrome]. / « Le syndrome du bébé secoué : les séquelles ? ¼

The Shaken Baby Syndrome (SBS) is a severe inflicted brain injury due to an adult violently shaking an infant. Diagnostic guidelines have been recently published by the "Haute Autorité de santé". The mortality rate after SBS is 21.6 % and the long-term outcome is good for only 8 to 36 % patients followed over more than 5 years. The aim of this article is to describe sequelae after a SBS, their mechanisms, prognostic factors and recommendations for a better long-term care of the patients.

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.

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.

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.

Long-term outcome of the shaken baby syndrome and medicolegal consequences: a case report.

INTRODUCTION: Studies of long-term outcome of the shaken baby syndrome (SBS) are scarce, but they usually indicate poor outcome. OBJECTIVES: To describe long-term outcome of a child having sustained a SBS, to ascertain possible delayed sequelae and to discuss medicolegal issues. METHODS: We report a single case study of a child having sustained a SBS, illustrating the initial clinical features, the neurological, cognitive and behavioural outcomes as well as her social integration. RESULTS: The child sustained diffuse brain injuries, responsible for spastic right hemiplegia leading to secondary orthopaedic consequences, as well as severe cognitive impairment, worsening over time: the developmental quotient measured at 15 months of age was 55 and worsened as age increased. At 6 years and 8 months, the child's IQ had fallen to 40. Behavioural disorders became apparent only after several months and precluded any social integration. The child eventually had to be placed in a specialised education centre at age 5. DISCUSSION AND CONCLUSION: The SBS has a very poor outcome and major long-standing sequelae are frequent. Cognitive or behavioural sequelae can become apparent only after a long sign-free interval, due to increasing demands placed on the child during development. This case report confirms severity of early brain lesions and necessity for an extended follow-up by a multi-disciplinary team. From a medicolegal point of view, signaling the child to legal authorities allows protection of the child, but also conditions later compensation if sequelae compromise autonomy.

[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 the dysexecutive syndrome using execution of a cooking task.

Patients with a dysexecutive syndrome often have severe disabilities in daily life activities. The aims of this study were to use a naturalistic experimental task to assess patients' disabilities, and to study the nature of the cognitive disorders underlying them. Execution of a cooking task involving multi-tasking (Chevignard et al., 2000) was studied in 45 patients with a dysexecutive syndrome following acquired brain injury. Patients made significantly more errors and were slower than controls; more than half of the patients did not achieve the goal and demonstrated dangerous behaviours. Those results were significantly correlated to the results of the Six Elements Task and to a behavioural questionnaire. They were also correlated to brain injury severity and to patients' cooking habits. This naturalistic assessment is clinically relevant to better assess patients' dysexecutive impairments in complex activities of daily living. Correlations of the results in the cooking task with the neuropsychological assessment highlighted the role of the dysexecutive syndrome in patients' disabilities, indicating control alterations rather than planning disorders, difficulty in dealing with the environment, and inhibiting inappropriate actions. The role of attention and prospective memory was also underlined, whereas other cognitive functions did not influence task performance.