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1.
Neurology ; 97(7): e706-e719, 2021 08 17.
Artigo em Inglês | MEDLINE | ID: mdl-34400568

RESUMO

OBJECTIVE: To determine similarities and differences in key predictors of recovery of bimanual hand use and unimanual motor impairment after stroke. METHOD: In this prospective longitudinal study, 89 patients with first-ever stroke with arm paresis were assessed at 3 weeks and 3 and 6 months after stroke onset. Bimanual activity performance was assessed with the Adult Assisting Hand Assessment Stroke (Ad-AHA), and unimanual motor impairment was assessed with the Fugl-Meyer Assessment (FMA). Candidate predictors included shoulder abduction and finger extension measured by the corresponding FMA items (FMA-SAFE; range 0-4) and sensory and cognitive impairment. MRI was used to measure weighted corticospinal tract lesion load (wCST-LL) and resting-state interhemispheric functional connectivity (FC). RESULTS: Initial Ad-AHA performance was poor but improved over time in all (mild-severe) impairment subgroups. Ad-AHA correlated with FMA at each time point (r > 0.88, p < 0.001), and recovery trajectories were similar. In patients with moderate to severe initial FMA, FMA-SAFE score was the strongest predictor of Ad-AHA outcome (R 2 = 0.81) and degree of recovery (R 2 = 0.64). Two-point discrimination explained additional variance in Ad-AHA outcome (R 2 = 0.05). Repeated analyses without FMA-SAFE score identified wCST-LL and cognitive impairment as additional predictors. A wCST-LL >5.5 cm3 strongly predicted low to minimal FMA/Ad-AHA recovery (≤10 and 20 points respectively, specificity = 0.91). FC explained some additional variance to FMA-SAFE score only in unimanual recovery. CONCLUSION: Although recovery of bimanual activity depends on the extent of corticospinal tract injury and initial sensory and cognitive impairments, FMA-SAFE score captures most of the variance explained by these mechanisms. FMA-SAFE score, a straightforward clinical measure, strongly predicts bimanual recovery. CLINICALTRIALSGOV IDENTIFIER: NCT02878304. CLASSIFICATION OF EVIDENCE: This study provides Class I evidence that the FMA-SAFE score predicts bimanual recovery after stroke.


Assuntos
Disfunção Cognitiva/fisiopatologia , Conectoma , Mãos/fisiopatologia , Avaliação de Resultados em Cuidados de Saúde , Paresia/fisiopatologia , Desempenho Psicomotor/fisiologia , Recuperação de Função Fisiológica/fisiologia , Acidente Vascular Cerebral/fisiopatologia , Adulto , Idoso , Disfunção Cognitiva/diagnóstico , Disfunção Cognitiva/etiologia , Feminino , Humanos , Estudos Longitudinais , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Paresia/diagnóstico , Paresia/etiologia , Prognóstico , Índice de Gravidade de Doença , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/diagnóstico
2.
J Rehabil Med ; 53(7): jrm00213, 2021 Jul 06.
Artigo em Inglês | MEDLINE | ID: mdl-34037240

RESUMO

OBJECTIVE: To evaluate the feasibility of using a wearable eye-tracker when assessing patients with prolonged disorders of consciousness using the Coma Recovery Scale Revised (CRS-R), focusing on technical challenges. DESIGN: A methodological investigation with descriptive and analytical elements. SUBJECTS: Four patients with prolonged disorders of consciousness were recruited from the rehabilitation clinic of a regional rehabilitation unit. METHODS: A selection of subtests in the CRS-R were performed while recording eye movements with a wearable eye-tracker. RESULTS: No major adverse reactions were observed, suggesting likely patient acceptability. Calibration was not always possible. However, distinct eye movements were discernible from the recorded data even without calibration, and analysis of these produced results with the potential to support clinical assessment. CONCLUSION: Eye tracking was feasible during clinical assessment for this patient group. Recording eye movement responses in these easily fatigued patients has the potential to add sensitivity for detection of conscious responses and to complement clinical examination. Further study is merited. Current hardware and software limitations can be overcome with manual data processing and analysis; however, significant developments in automating data processing will be required for broader clinical application.


Assuntos
Transtornos da Consciência/diagnóstico , Tecnologia de Rastreamento Ocular , Dispositivos Eletrônicos Vestíveis , Adulto , Tecnologia de Rastreamento Ocular/efeitos adversos , Estudos de Viabilidade , Humanos , Escala de Gravidade do Ferimento , Satisfação do Paciente , Dispositivos Eletrônicos Vestíveis/efeitos adversos , Adulto Jovem
3.
Front Neurol ; 10: 836, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31456734

RESUMO

Objective: This longitudinal observational study investigated how neural stretch-resistance in wrist and finger flexors develops after stroke and relates to motor recovery, secondary complications, and lesion location. Methods: Sixty-one patients were assessed at 3 weeks (T1), three (T2), and 6 months (T3) after stroke using the NeuroFlexor method and clinical tests. Magnetic Resonance Imaging was used to calculate weighted corticospinal tract lesion load (wCST-LL) and to perform voxel-based lesion symptom mapping. Results: NeuroFlexor assessment demonstrated spasticity (neural component [NC] >3.4N normative cut-off) in 33% of patients at T1 and in 51% at T3. Four subgroups were identified: early Severe spasticity (n = 10), early Moderate spasticity (n = 10), Late developing spasticity (n = 17) and No spasticity (n = 24). All except the Severe spasticity group improved significantly in Fugl-Meyer Assessment (FMA-HAND) to T3. The Severe and Late spasticity groups did not improve in Box and Blocks Test. The Severe spasticity group showed a 25° reduction in passive range of movement and more frequent arm pain at T3. wCST-LL correlated positively with NC at T1 and T3, even after controlling for FMA-HAND and lesion volume. Voxel-based lesion symptom mapping showed that lesioned white matter below cortical hand knob correlated positively with NC. Conclusion: Severe hand spasticity early after stroke is negatively associated with hand motor recovery and positively associated with the development of secondary complications. Corticospinal tract damage predicts development of spasticity. Early quantitative hand spasticity measurement may have potential to predict motor recovery and could guide targeted rehabilitation interventions after stroke.

4.
BMJ Open ; 8(2): e018734, 2018 02 03.
Artigo em Inglês | MEDLINE | ID: mdl-29431132

RESUMO

OBJECTIVES: To assess (1) whether visual disturbances can be demonstrated with objective measures more often in patients with mild traumatic brain injury (mTBI) than in orthopaedic controls and non-injured controls, (2) whether such objectively demonstrated disturbances change over time and (3) whether self-reported visual symptoms after mTBI correlate with objectively measurable changes in visuomotor performance. DESIGN: A prospective, controlled, observational study, with assessments planned 7-10 and 75-100 days after injury. SETTING: Emergency department of a general hospital in Sweden. PARTICIPANTS: 15 patients with mTBI, 15 patients with minor orthopaedic injury, 15 non-injured controls, aged 18-40 years. OUTCOME MEASURES: Visual examination, including assessment of visual acuity, accommodation, eye alignment, saccades and stereoacuity. Symptom assessment using Convergence Insufficiency Symptoms Survey (CISS) and Rivermead PostConcussion Symptoms Questionnaire. RESULTS: Assessments were performed 4-13 and 81-322 days after injury (extended time frames for logistical reasons). No statistically significant difference was found between the mTBI and control groups regarding saccade performance and stereoacuity at any time point. The accommodative amplitude was significantly lower in the mTBI group compared with non-injured controls at baseline. 6 out of 13 patients with mTBI had accommodative insufficiency at follow-up. Near point of convergence in the mTBI group was receded at baseline and improved statistically significantly at follow-up. At baseline, patients with mTBI had significantly higher CISS score than orthopaedic and non-injured controls. For patients with mTBI, the CISS score correlated with fusional vergence. CONCLUSION: There were some transient measurable visual changes regarding convergence in patients with mTBI during the subacute period after the injury. Our findings of persistence of accommodative insufficiency in a considerable proportion of patients with mTBI suggest that this visual function should not be overlooked in clinical assessment.


Assuntos
Concussão Encefálica/complicações , Transtornos da Motilidade Ocular/fisiopatologia , Transtornos da Visão/fisiopatologia , Acomodação Ocular , Adolescente , Adulto , Concussão Encefálica/fisiopatologia , Estudos de Casos e Controles , Feminino , Humanos , Estudos Longitudinais , Masculino , Estudos Prospectivos , Índice de Gravidade de Doença , Suécia , Acuidade Visual , Adulto Jovem
5.
J Rehabil Med ; 50(3): 253-260, 2018 Feb 28.
Artigo em Inglês | MEDLINE | ID: mdl-29313873

RESUMO

OBJECTIVE: To explore whether the use of personally relevant stimuli, for some tasks in the Coma Recovery Scale - Revised (CRS-R), generates more responses in patients with prolonged disorders of consciousness compared with neutral stimuli. DESIGN: Multiple single-case design. SUBJECTS: Three patients with prolonged disorders of consciousness recruited from an inpatient department at a regional brain injury rehabilitation clinic in Stockholm, Sweden. METHODS: Patients were repeatedly assessed with the CRS-R. Randomization tests (bootstrapping) were used to compare the number of responses generated by personally relevant and neutral stimuli on 5 items in the CRS-R. RESULTS: Compared with neutral stimuli, photographs of relatives generated significantly more visual fixations. A mirror generated visual pursuit to a significantly greater extent than other self-relevant stimuli. On other items, no significant differences between neutral and personally relevant stimuli were seen. CONCLUSION: Personally relevant visual stimuli may minimize the risk of missing visual fixation, compared with the neutral stimuli used in the current gold standard behavioural assessment measure (CRS-R). However, due to the single-subject design this conclusion is tentative and more research is needed.


Assuntos
Coma/diagnóstico , Estado de Consciência/fisiologia , Adulto , Feminino , Humanos , Masculino , Projetos Piloto
6.
Clin Rehabil ; 31(4): 555-566, 2017 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-27277217

RESUMO

OBJECTIVE: To investigate the occurrence of behavioural problems in patients with severe traumatic brain injury during the first year after injury and potential associations with outcome. An additional post hoc objective was to analyse the frequency of behaviours with need for intervention from staff. DESIGN AND SETTING: In a prospective population based cohort study 114 patients with severe traumatic brain injury were assessed at three weeks, three months and one year after injury. MAIN MEASURES: Assessments included clinical examination and standardised instruments. Agitation was assessed with the Agitated Behaviour Scale, the course of recovery by the Rancho Los Amigo Scale and outcome by Glasgow Outcome Scale Extended. RESULTS: Agitation were most common at 3 weeks post injury and 28% ( n=68) of the patients showed at least one agitated behaviour requiring intervention from staff. Presence of significant agitation at 3 weeks after injury was not associated with poor outcome. At 3 months agitation was present in 11% ( n=90) and apathy in 26 out of 81 assessed patients. At 3 months agitation and apathy were associated with poor outcome at one year. CONCLUSIONS: Most agitated behaviours in the early phase are transient and are not associated with poor outcome. Agitation and apathy are uncommon at three months but when present are associated with poor outcome at one year after injury. In the early phase after a severe traumatic brain injury agitated behaviour in need of interventions from staff occur in a substantial proportion of patients.


Assuntos
Apatia , Lesões Encefálicas Traumáticas/complicações , Depressão/psicologia , Comportamento Problema/psicologia , Agitação Psicomotora/psicologia , Adolescente , Adulto , Idoso , Lesões Encefálicas Traumáticas/psicologia , Depressão/diagnóstico , Feminino , Escala de Coma de Glasgow , Escala de Resultado de Glasgow , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Agitação Psicomotora/diagnóstico , Agitação Psicomotora/etiologia , Adulto Jovem
8.
J Rehabil Med ; 48(1): 1-5, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26660510

RESUMO

OBJECTIVE: To undertake a systematic review of the evidence for the effect of acetylcholinesterase inhibitors (AChEIs) on cognition late after moderate or severe traumatic brain injury. BACKGROUND: Cognitive impairment after traumatic brain injury has significant consequences for the individual and society. Cholinergic pathways play an important role in cognitive processing and a hypocholinergic state exists in the chronic phases after traumatic brain injury. AChEIs are already used off-label to treat patients with traumatic brain injury. DATA SOURCES AND STUDY SELECTION: PubMed, CINAHL, PsycINFO, the Cochrane Collaboration and Web of Science were searched with pre-specified criteria between 1999 and June 2015. DATA EXTRACTION AND SYNTHESIS: A total of 153 studies were identified. None met pre-specified criteria. The criteria were revised in order to identify studies that may provide useful information despite some risk of bias. Three studies met the revised criteria and were evaluated by 2 reviewers using the Swedish Council on Health Technology Assessment grading system, based on GRADE. Key findings and limitations were tabulated. One study found no effect and 2 found limited effect. CONCLUSION: Large randomized controlled studies are needed to establish whether AChEIs are effective for cognition late after moderate or severe traumatic brain injury. Clinicians should be aware of the weak evidence base when considering the off-label use of AChEIs.


Assuntos
Lesões Encefálicas/tratamento farmacológico , Inibidores da Colinesterase/uso terapêutico , Transtornos Cognitivos/tratamento farmacológico , Lesões Encefálicas/complicações , Transtornos Cognitivos/etiologia , Humanos , Uso Off-Label , Avaliação de Resultados da Assistência ao Paciente
9.
BMJ Open ; 5(4): e007208, 2015 May 03.
Artigo em Inglês | MEDLINE | ID: mdl-25941181

RESUMO

BACKGROUND: Medical complications after severe traumatic brain injury (S-TBI) may delay or prevent transfer to rehabilitation units and impact on long-term outcome. OBJECTIVE: Mapping of medical complications in the subacute period after S-TBI and the impact of these complications on 1-year outcome to inform healthcare planning and discussion of prognosis with relatives. SETTING: Prospective multicentre observational study. Recruitment from 6 neurosurgical centres in Sweden and Iceland. PARTICIPANTS AND ASSESSMENTS: Patients aged 18-65 years with S-TBI and acute Glasgow Coma Scale 3-8, who were admitted to neurointensive care. Assessment of medical complications 3 weeks and 3 months after injury. Follow-up to 1 year. 114 patients recruited with follow-up at 1 year as follows: 100 assessed, 7 dead and 7 dropped out. OUTCOME MEASURE: Glasgow Outcome Scale Extended. RESULTS: 68 patients had ≥1 complication 3 weeks after injury. 3 weeks after injury, factors associated with unfavourable outcome at 1 year were: tracheostomy, assisted ventilation, on-going infection, epilepsy and nutrition via nasogastric tube or percutaneous endoscopic gastroscopy (PEG) tube (univariate logistic regression analyses). Multivariate analysis demonstrated that tracheostomy and epilepsy retained significance even after incorporating acute injury severity into the model. 3 months after injury, factors associated with unfavourable outcome were tracheostomy and heterotopic ossification (Fisher's test), infection, hydrocephalus, autonomic instability, PEG feeding and weight loss (univariate logistic regression). PEG feeding and weight loss at 3 months were retained in a multivariate model. CONCLUSIONS: Subacute complications occurred in two-thirds of patients. Presence of a tracheostomy or epilepsy at 3 weeks, and of PEG feeding and weight loss at 3 months, had robust associations with unfavourable outcome that were incompletely explained by acute injury severity.


Assuntos
Lesões Encefálicas/reabilitação , Nutrição Enteral/estatística & dados numéricos , Epilepsia/epidemiologia , Respiração Artificial/estatística & dados numéricos , Insuficiência Respiratória/epidemiologia , Traqueostomia/estatística & dados numéricos , Adolescente , Adulto , Idoso , Doenças do Sistema Nervoso Autônomo/epidemiologia , Lesões Encefálicas/epidemiologia , Feminino , Escala de Resultado de Glasgow , Humanos , Hidrocefalia/epidemiologia , Islândia , Infecções/epidemiologia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Ossificação Heterotópica/epidemiologia , Prognóstico , Estudos Prospectivos , Recuperação de Função Fisiológica , Suécia , Índices de Gravidade do Trauma , Perda de Peso , Adulto Jovem
10.
Behav Neurol ; 2015: 680308, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26783381

RESUMO

OBJECTIVE: To assess the clinical course of cognitive and emotional impairments in patients with severe TBI (sTBI) from 3 weeks to 1 year after trauma and to study associations with outcomes at 1 year. METHODS: Prospective, multicenter, observational study of sTBI in Sweden and Iceland. Patients aged 18-65 years with acute Glasgow Coma Scale 3-8 were assessed with the Barrow Neurological Institute Screen for Higher Cerebral Functions (BNIS) and the Hospital Anxiety and Depression Scale (HADS). Outcome measures were Glasgow Outcome Scale Extended (GOSE) and Rancho Los Amigos Cognitive Scale-Revised (RLAS-R). RESULTS: Cognition was assessed with the BNIS assessed for 42 patients out of 100 at 3 weeks, 75 patients at 3 months, and 78 patients at 1 year. Cognition improved over time, especially from 3 weeks to 3 months. The BNIS subscales "orientation" and "visuospatial and visual problem solving" were associated with the GOSE and RLAS-R at 1 year. CONCLUSION: Cognition seemed to improve over time after sTBI and appeared to be rather stable from 3 months to 1 year. Since cognitive function was associated with outcomes, these results indicate that early screening of cognitive function could be of importance for rehabilitation planning in a clinical setting.


Assuntos
Lesões Encefálicas/complicações , Transtornos Cognitivos/diagnóstico , Avaliação de Resultados em Cuidados de Saúde , Índices de Gravidade do Trauma , Adolescente , Adulto , Idoso , Transtornos Cognitivos/etiologia , Progressão da Doença , Feminino , Escala de Coma de Glasgow , Escala de Resultado de Glasgow , Humanos , Islândia , Masculino , Pessoa de Meia-Idade , Suécia , Adulto Jovem
11.
J Head Trauma Rehabil ; 30(3): E41-51, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-24901323

RESUMO

OBJECTIVE: To assess associations between real-world care pathways for working-age patients in the first year after severe traumatic brain injury and outcomes at 1 year. SETTING AND DESIGN: Prospective, observational study with recruitment from 6 neurosurgical centers in Sweden and Iceland. Follow-up to 1 year, independently of care pathways, by rehabilitation physicians and paramedical professionals. PARTICIPANTS: Patients with severe traumatic brain injury, lowest (nonsedated) Glasgow Coma Scale score 3 to 8 during the first 24 hours and requiring neurosurgical intensive care, age 18 to 65 years, and alive 3 weeks after injury. MAIN MEASURES: Length of stay in intensive care, time between intensive care discharge and rehabilitation admission, outcome at 1 year (Glasgow Outcome Scale Extended score), acute markers of injury severity, preexisting medical conditions, and post-acute complications. Logistic regression analyses were performed. RESULTS: A multivariate model found variables significantly associated with outcome (odds ratio for good outcome [confidence interval], P value) to be as follows: length of stay in intensive care (0.92 [0.87-0.98], 0.014), time between intensive care discharge and admission to inpatient rehabilitation (0.97 [0.94-0.99], 0.017), and post-acute complications (0.058 [0.006-0.60], 0.017). CONCLUSIONS: Delays in rehabilitation admission were negatively associated with outcome. Measures to ensure timely rehabilitation admission may improve outcome. Further research is needed to evaluate possible causation.


Assuntos
Lesões Encefálicas/terapia , Cuidados Críticos , Procedimentos Clínicos , Adolescente , Adulto , Idoso , Lesões Encefálicas/diagnóstico , Lesões Encefálicas/etiologia , Escala de Coma de Glasgow , Humanos , Islândia , Tempo de Internação , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Estudos Prospectivos , Suécia , Fatores de Tempo , Adulto Jovem
12.
Arch Phys Med Rehabil ; 95(3 Suppl): S210-29, 2014 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-24581907

RESUMO

OBJECTIVE: To synthesize the best available evidence on prognosis after sport concussion. DATA SOURCES: MEDLINE and other databases were searched (2001-2012) with terms including "craniocerebral trauma" and "sports." Reference lists of eligible articles were also searched. STUDY SELECTION: Randomized controlled trials and cohort and case-control studies were selected according to predefined criteria. Studies had to have a minimum of 30 concussion cases. DATA EXTRACTION: Eligible studies were critically appraised using a modification of the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Two reviewers independently reviewed and extracted data from accepted studies into evidence tables. DATA SYNTHESIS: Evidence was synthesized qualitatively according to modified SIGN criteria, and studies were categorized as exploratory or confirmatory based on the strength of their design and evidence. After 77,914 records were screened, 52 articles were eligible for this review, and 24 articles (representing 19 studies) with a low risk of bias were accepted. Our findings are based on exploratory studies of predominantly male football players at the high school, collegiate, and professional levels. Most athletes recover within days to a few weeks, and American and Australian professional football players return to play quickly after mild traumatic brain injury. Delayed recovery appears more likely in high school athletes, in those with a history of previous concussion, and in those with a higher number and duration of postconcussion symptoms. CONCLUSIONS: The evidence concerning sports concussion course and prognosis is very preliminary, and there is no evidence on the effect of return-to-play guidelines on prognosis. Our findings have implications for further research. Well-designed, confirmatory studies are urgently needed to understand the consequences of sport concussion, including recurrent concussion, across different athletic populations and sports.


Assuntos
Atletas , Concussão Encefálica/diagnóstico , Recuperação de Função Fisiológica , Esportes , Índices de Gravidade do Trauma , Concussão Encefálica/complicações , Transtornos Cognitivos/etiologia , Humanos , Testes Neuropsicológicos , Síndrome Pós-Concussão/diagnóstico , Síndrome Pós-Concussão/etiologia , Prognóstico , Recidiva
13.
Arch Phys Med Rehabil ; 95(3 Suppl): S245-56, 2014 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-24581910

RESUMO

OBJECTIVE: To synthesize the best available evidence regarding the risk of dementia and chronic cognitive impairment (CCI) after mild traumatic brain injury (MTBI). DATA SOURCES: MEDLINE and other databases were searched (2001-2012) using a previously published search strategy and predefined criteria. Peer-reviewed reports in 6 languages were considered. STUDY SELECTION: Systematic reviews, meta-analyses, randomized controlled trials, cohort studies, and case-control studies, with a minimum of 30 MTBI cases in subjects of any age, assessing the risk of dementia or CCI after MTBI were selected. DATA EXTRACTION: Eligible studies were critically appraised using a modification of the Scottish Intercollegiate Guidelines Network criteria. Two reviewers independently reviewed each study and extracted data from accepted articles (ie, with a low risk of bias) into evidence tables. DATA SYNTHESIS: Evidence from accepted studies was synthesized qualitatively according to modified Scottish Intercollegiate Guidelines Network criteria, and prognostic information was prioritized as exploratory or confirmatory according to design. Of 77,914 records screened, 299 articles were eligible and reviewed. Methodological quality was acceptable for 101 (34%) articles, of which 1 article considered dementia and 7 articles considered CCI. The study examining the risk of dementia after MTBI did not find an association. One randomized controlled trial found that being informed about possible cognitive dysfunction after MTBI was associated with worse cognitive performance on standard tests. Children with MTBI and intracranial pathology ("complicated" MTBI) performed worse than did children without intracranial pathology. Children showed higher rates of cognitive symptoms a year after MTBI than did a control group. CONCLUSIONS: There is a lack of evidence of an increased risk of dementia after MTBI. In children, objective evidence of CCI exists only for complicated MTBI. More definitive studies are needed to inform clinical decisions, assessment of prognosis, and public health policy.


Assuntos
Lesões Encefálicas/diagnóstico , Lesões Encefálicas/terapia , Disfunção Cognitiva/etiologia , Demência/etiologia , Índices de Gravidade do Trauma , Lesões Encefálicas/complicações , Humanos , Prognóstico
14.
Arch Phys Med Rehabil ; 95(3 Suppl): S257-64, 2014 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-24581911

RESUMO

OBJECTIVE: To synthesize the best available evidence regarding the impact of nonsurgical interventions on persistent symptoms after mild traumatic brain injury (MTBI). DATA SOURCES: MEDLINE and other databases were searched (2001-2012) with terms including "rehabilitation." Inclusion criteria were original, peer-reviewed research published in English and other languages. References were also identified from the bibliographies of eligible articles. STUDY SELECTION: Controlled trials and cohort and case-control studies were selected according to predefined criteria. Studies had to have a minimum of 30 MTBI cases and assess nonsurgical interventions using clinically relevant outcomes such as self-rated recovery. DATA EXTRACTION: Eligible studies were critically appraised using a modification of the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Two reviewers independently reviewed each study and extracted data from the admissible studies into evidence tables. DATA SYNTHESIS: The evidence was synthesized qualitatively according to the modified SIGN criteria. Recommendations were linked to the evidence tables using a best-evidence synthesis. After 77,914 records were screened, only 2 of 7 studies related to nonsurgical interventions were found to have a low risk of bias. One studied the effect of a scheduled telephone intervention offering counseling and education on outcome and found a significantly better outcome for symptoms (6.6 difference in adjusted mean symptom score; 95% confidence interval, 1.2-12.0), but no difference in general health outcome at 6 months after MTBI. The other was a randomized controlled trial of the effectiveness of 6 days of bed rest on posttraumatic complaints 6 months postinjury, compared with no bed rest, and found no effect. CONCLUSIONS: Some evidence suggests that early, reassuring educational information is beneficial after MTBI. Well-designed intervention studies are required to develop effective treatments and improve outcomes for adults and children at risk for persistent symptoms after MTBI.


Assuntos
Lesões Encefálicas/diagnóstico , Lesões Encefálicas/terapia , Índices de Gravidade do Trauma , Humanos , Prognóstico
15.
Arch Phys Med Rehabil ; 95(3 Suppl): S265-77, 2014 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-24581912

RESUMO

The International Collaboration on Mild Traumatic Brain Injury (MTBI) Prognosis performed a comprehensive search and critical review of the literature from 2001 to 2012 to update the 2002 best-evidence synthesis conducted by the World Health Organization Collaborating Centre for Neurotrauma, Prevention, Management and Rehabilitation Task Force on the prognosis of MTBI. Of 299 relevant studies, 101 were accepted as scientifically admissible. The methodological quality of the research literature on MTBI prognosis has not improved since the 2002 Task Force report. There are still many methodological concerns and knowledge gaps in the literature. Here we report and make recommendations on how to avoid methodological flaws found in prognostic studies of MTBI. Additionally, we discuss issues of MTBI definition and identify topic areas in need of further research to advance the understanding of prognosis after MTBI. Priority research areas include but are not limited to the use of confirmatory designs, studies of measurement validity, focus on the elderly, attention to litigation/compensation issues, the development of validated clinical prediction rules, the use of MTBI populations other than hospital admissions, continued research on the effects of repeated concussions, longer follow-up times with more measurement periods in longitudinal studies, an assessment of the differences between adults and children, and an account for reverse causality and differential recall bias. Well-conducted studies in these areas will aid our understanding of MTBI prognosis and assist clinicians in educating and treating their patients with MTBI.


Assuntos
Pesquisa Biomédica/métodos , Lesões Encefálicas/classificação , Lesões Encefálicas/diagnóstico , Índices de Gravidade do Trauma , Viés , Pesquisa Biomédica/normas , Concussão Encefálica/classificação , Concussão Encefálica/diagnóstico , Seguimentos , Escala de Coma de Glasgow , Humanos , Valor Preditivo dos Testes , Prognóstico , Reprodutibilidade dos Testes , Organização Mundial da Saúde
16.
J Rehabil Med ; 45(8): 741-8, 2013 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-24002309

RESUMO

BACKGROUND: Very severe traumatic brain injury may cause disorders of consciousness in the form of coma, unresponsive wakefulness syndrome (also known as vegetative state) or minimally conscious state. Previous studies of outcome for these patients largely pre-date the 2002 definition of minimally conscious state. OBJECTIVES: To establish the numbers of patients with disorder of consciousness at 3 weeks, 3 months and 1 year after severe traumatic brain injury, and to relate conscious state 3 weeks after injury to outcomes at 1 year. DESIGN: Multi-centre, prospective, observational study of severe traumatic brain injury. INCLUSION CRITERIA: lowest (non-sedated) Glasgow Coma Scale 3-8 during the first 24 h; requirement for neurosurgical intensive care; age 18-65 years; alive 3 weeks after injury. Diagnosis of coma, unresponsive wakefulness syndrome, minimally conscious state or emerged from minimally conscious state was based on clinical and Coma Recovery Scale Revised assessments 3 weeks, 3 months and 1 year after injury. One-year outcome was measured with Glasgow Outcome Scale Extended (GOSE). RESULTS: A total of 103 patients was included in the study. Of these, 81% were followed up to 1 year (76% alive, 5% dead). Three weeks after injury 36 were in coma, unresponsive wakefulness syndrome or minimally conscious state and 11 were anaesthetized. Numbers of patients who had emerged from minimally conscious state 1 year after injury, according to status at 3 weeks were: coma (0/6), unresponsive wakefulness syndrome (9/17), minimally conscious state (13/13), anaesthetized (9/11). Outcome at 1 year was good (GOSE > 4) for half of patients in minimally conscious state or anaesthetized at 3 weeks, but for none of the patients in coma or unresponsive wakefulness syndrome. These differences in outcome were not revealed by prognostic predictions based on acute data. CONCLUSION: Patients in minimally conscious state or anaesthetized 3 weeks after injury have a better prognosis than patients in coma or unresponsive wakefulness syndrome, which could not be explained by acute prognostic models.


Assuntos
Lesões Encefálicas/complicações , Inconsciência/diagnóstico , Adolescente , Adulto , Idoso , Feminino , Escala de Resultado de Glasgow , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Inconsciência/etiologia , Adulto Jovem
17.
Brain Inj ; 26(2): 188-93, 2012.
Artigo em Inglês | MEDLINE | ID: mdl-22360525

RESUMO

BACKGROUND: The use of validated behavioural assessment scales in assessment of patients with Disorders of Consciousness (DOC) is well established. However, there is little evidence to guide decisions on total time spent in behavioural assessment. OBJECTIVE: To assess whether brief behavioural assessment was as effective as extended behavioural assessment in detecting non-vegetative behaviours. METHODS: Consecutive patients with suspected DOC were assessed with two standardized instruments: Coma Recovery Scale Revised (CRS-R) and Sensory Modality Assessment and Rehabilitation Technique (SMART). Assessors were blinded to results from the other scale at the point of assessment. Two administrations of CRS-R together took 50-60 minutes ('brief' assessment). One complete SMART assessment took 600 minutes ('extended' assessment). Patients were classified as being in a vegetative state (VS) or minimally conscious state (MCS)/emerged from minimally conscious state (EMCS), following brief and extended assessment. RESULTS: Ten patients were assessed. Brief and extended assessment yielded the same diagnostic category (VS or MCS) for six patients and different categories for four, with extended assessment detecting higher level behaviours. CONCLUSIONS: Brief behavioural assessment was not as effective as extended assessment in detecting non-vegetative behaviours. Total time spent in behavioural assessment is likely important. Further studies and clearer clinical guidance are needed.


Assuntos
Lesões Encefálicas/fisiopatologia , Estado Vegetativo Persistente/fisiopatologia , Adulto , Idoso , Lesões Encefálicas/psicologia , Lesões Encefálicas/reabilitação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica , Estado Vegetativo Persistente/psicologia , Estado Vegetativo Persistente/reabilitação , Prognóstico , Estudos Prospectivos , Psicometria , Recuperação de Função Fisiológica , Índices de Gravidade do Trauma
19.
Am J Phys Med Rehabil ; 90(6): 482-9, 2011 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-21389839

RESUMO

OBJECTIVE: : The aim of this study was to document physicians' opinions on inpatient rehabilitation care for working-age patients in vegetative state after new acquired brain injury, given the absence of an established standard of post-acute care. DESIGN: : A postal survey of 3259 Swedish physicians was conducted. RESULTS: : Survey response rate was 33%. Of survey respondents, 51% reported that they knew the definition of vegetative state. Transfer of vegetative patients from acute care to inpatient rehabilitation was considered always warranted by 54% and never or only sometimes warranted by 31% of survey respondents, whereas 15% did not know or did not answer. Rehabilitation physicians most often considered an inpatient rehabilitation stay of around 3 mos to be appropriate, but there was a lack of consensus. Discharge from acute care direct to social care at least sometimes was reported by 39% of physicians. CONCLUSIONS: : Physicians' opinions vary considerably on appropriate post-acute care for patients in vegetative state after acquired brain injury. This may impact on rates of referral and admission to rehabilitation units. Consensus is needed on a minimum period for and extent of rehabilitation interventions. Educational interventions should be targeted broadly to reach the wide range of specialties that may have responsibility for acute care of these patients.


Assuntos
Atitude do Pessoal de Saúde , Lesões Encefálicas/diagnóstico , Lesões Encefálicas/reabilitação , Pacientes Internados/estatística & dados numéricos , Papel do Médico , Adulto , Continuidade da Assistência ao Paciente/normas , Continuidade da Assistência ao Paciente/tendências , Feminino , Pesquisas sobre Serviços de Saúde , Hospitais Universitários , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Alta do Paciente/estatística & dados numéricos , Estado Vegetativo Persistente , Padrões de Prática Médica/tendências , Prognóstico , Centros de Reabilitação , Medição de Risco , Inquéritos e Questionários , Suécia
20.
BMJ ; 337: a2586, 2008 Nov 19.
Artigo em Inglês | MEDLINE | ID: mdl-19019867

Assuntos
Nomes , Médicos , Suécia
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