Why evaluate one-week-delayed verbal recall in patients with severe traumatic brain injury?

PRIMARY OBJECTIVE: The aim of this study was to propose new measures to evaluate memory processes in patients with severe traumatic brain injury (TBI). In this purpose, we analyzed learning and consolidation processes depending on own patient's performance during a memory test. METHODS: One-week Free and Cued Selective Reminding Test - word version (1W-FCSRT-word), which special feature relies on a 30-min and a 1-week-delayed recall after encoding, was administered to a group of 43 patients with severe TBI (age range from 20 to 54 years) and a group of neurologically healthy volunteers matched for age and gender. RESULTS: Patients performed worse than healthy volunteers for the learning score. Their forgetting percentage was above healthy volunteers' performance and difference between the two groups increased with the delay from the learning phase. CONCLUSION: In patients with severe TBI, our results underlined an altered learning and an impairment of long-term consolidation. It is crucial to detect these deficits in the aim to highlight, with a better accuracy, these patients' memory complaints and to propose a better professional rehabilitation.

Construction and pilot assessment of the Upper Limb Assessment in Daily Living Scale.

OBJECTIVE: The upper limb function of hemiplegic patients is currently evaluated using scales that assess physical capacity or daily activities under test conditions. The present scale, the Upper Limb Assessment in Daily Living (ULADL) Scale, was developed to explore the subjective and objective functional capacities of such patients in a proximal to distal sequence. METHODS: A group of experts constructed a scale addressing 17 upper limb functions (five active passive and 12 active) which could be explored by a questionnaire (Q) and a test (T). Reproducibility, internal consistency, concurrent validity (Rivermead Motor Assessment (RMA)) and learning effect were estimated in a multicentre study. RESULTS: 49 stroke patients were each rated three times within 7 days by a total of 21 physicians, yielding a total of 142 ratings. The ULADL took 16±8 min to complete compared with 9±5 min for the RMA. Cronbach's alpha coefficient was 0.95 for Q and 0.97 for the practical tests (T). The global Q and T scores, and in particular the global Q score, were slightly higher at the second rating. The intra-rater intraclass correlation coefficient (ICC) was 0.65 (95% CI (0.44 to 0.79)) for Q and 0.97 (0.95 to 0.98) for T, and the inter-rater ICC was 0.95 for both Q and T. The Bland and Altman method showed good intra- and inter-rater reliability with no systematic trend. Correlation coefficients for ULADL versus RMA were >0.80 for both Q and T. CONCLUSIONS: The ULADL Scale has good psychometric properties and can explore patients with different degrees of upper limb impairment.

The relationship between cognition and vocational training outcome in patients with acquired brain injury: Contribution of Machine Learning.

The aim of this study was to identify specific cognitive patterns related to long-term vocational training outcome. Records of twenty-eight patients who had benefited from a professional rehabilitation program were retrospectively processed. Screening through machine learning algorithms of patients' neuropsychological scores identified cognitive patterns related to both vocational training outcomes: succeeded or failed. These patterns were based on cognitive performance intervals even if the cognitive ability was not impaired. The cognitive pattern related to a successful vocational training included performance intervals on measures underlying verbal memory consolidation, visual memory incidental recall, problem solving and planning abilities. The cognitive pattern explaining failure of vocational training included performance intervals on tasks involving planning and problem solving abilities. From a comprehensive neuropsychological battery, memory and executive measures appeared to be the best attributes related to the vocational training outcome in patients with brain injury. Even with a cognitive functioning above the pathological cutoff, patients suffering from a brain injury could fail a vocational training. The attributes related to the vocational training outcome would be more a specific level of cognitive functioning rather than an interpretation of neuropsychological scores only based on a normal versus pathological distinction.

Impact of cognitive and behavioural functioning on vocational outcome following traumatic brain injury: a systematic review.

PURPOSE: Individuals with traumatic brain injury (TBI) often present injury-related cognitive and behavioural sequelae hindering a successful professional outcome, even many years after injury. The aim of this study was to investigate cognitive and behavioural factors predicting vocational outcome in the post-acute stages (≥one year) of TBI. METHODS: A systematic review of empirical research about vocational outcome of individuals with TBI was conducted. Studies published in PubMed and PsycINFO from 1 January 1998 to 31 May 2019 were screened. Only studies using the same injury severity criteria (the Glasgow Coma Scale score and/or the duration of post-traumatic amnesia) were selected. RESULTS: We found that (1) self-reported symptoms, (2) Functional Independence Measure and Mayo-Portland Adaptability Inventory Scores, (3) alcohol abuse and mood disorders, and (4) Differentiated Outcome Scale Cognitive Scores in individuals with TBI were highly predictive of the vocational outcome. CONCLUSION: This systematic review emphasized the link between cognitive and behavioural functioning and vocational rehabilitation in individuals with TBI. However, scientific literature lacks cognitive and behavioural models predicting vocational outcome of these individuals, including academic or vocational training. Such models would allow clinicians to improve vocational guidance of these individuals.Implications for rehabilitationCognitive and behavioural assessment is highly important even many years after traumatic brain injury, especially in a social and professional rehabilitation context.Clinicians should integrate objective measures of cognition and behaviour in post-acute phases of traumatic brain injury.Identifying vocational outcome related cognitive and behavioural patterns of functioning would allow clinicians to improve vocational guidance of adults with traumatic brain injury.

Is Multidimensional Fatigue Inventory (MFI-20) adequate to measure brain injury related fatigue?

BACKGROUND: Fatigue is a common symptom in patients with acquired brain injury (ABI) related disability while its multidimensionality has never been investigated, and specifically its relationship with patients' cognitive functioning. OBJECTIVE: This study aimed to evaluate the validity of the Multidimensional Fatigue Inventory (MFI-20) in patients living with ABI-related disability. METHODS: Four hundred twenty-six participants divided in three different groups (ABI-related disability, physical-related disability without an ABI, and healthy volunteers with no disability) were administered the French version of the Multidimensional Fatigue Inventory. We investigated the link between these fatigue measures and neuropsychological assessment in patients with ABI. Performance on this tool was compared according to the group and we calculated normative data for the Multidimensional Fatigue Inventory based on healthy volunteers' performance. RESULTS: In patients with ABI, fatigue measures significantly correlated with neuropsychological measures of attention, memory and executive functions. We found higher scores on Mental Fatigue and Reduced Activities dimensions in patients with ABI in comparison with the patients with physical disability (p < 0.05) and healthy controls (p < 0.01). CONCLUSIONS: The Multidimensional Fatigue Inventory appeared to be a sensitive tool to detect ABI-related fatigue, fatigue levels being higher than in patients with physical disability and in healthy volunteers. As fatigue appeared to be related to memory, executive and attentional functioning of patients with ABI-related disability who often face unemployment, its impact on vocational outcome following ABI should be further investigated.

Long-term effect of tibial nerve neurotomy in stroke patients with lower limb spasticity.

OBJECTIVES: We investigated the long-term effects and predictive indices of efficacy of tibial nerve neurotomy in a large series of patients with post-stroke hemiplegia. METHODS: Fifty-one patients were prospectively included, who showed disabling lower limb deformity (equinus, varus, clawing toes). The motor branches of the tibial nerve were selected according to the type of deformity, and partially resected at the posterior part of the calf. Patients were regularly assessed, before surgery and from the third month to the second year post surgery, for spasticity (primary outcome measure), motor control, range of active and passive movements, balance, walk, gait parameters, Rivermead Motor Assessment (RMA), subjective improvement and satisfaction. RESULTS: Neurotomy definitely reduced spasticity and improved motor control on antagonist muscles, while improving balance, walk, and the RMA. These effects were clearly perceived in daily living. A discrete decline was at times observed at 2 years. Functional improvement was greater in patients more severely impaired. Side effects, consisting in sensory disorders, were observed following neurotomy of the motor fascicles of the flexor digitorum longus. CONCLUSIONS: Tibial nerve neurotomy showed great and lasting effects, and can be proposed to improve walking and balance in stroke patients with disabling lower limb deformity.

Effects of tibial nerve neurotomy on posture and gait in stroke patients: A focus on patient-perceived benefits in daily life.

OBJECTIVE: To evaluate the objective and subjective functional effectiveness of tibial nerve neurotomy (TNN) in post-stroke spastic equinovarus foot (SEF). METHODS: In an open study, 23 hemiplegic patients were assessed immediately before TNN and then 5months after TNN. The main outcome measure was the Lower Limb Function Assessment Scale (LL-FAS), which provided an ecologic assessment of impairments in standing and walking (i.e. kinematic abnormalities) and their impacts on activities of daily living. Patients were also assessed for global clinical impression of change, fear of falling, neuromotor impairments, spatiotemporal and video gait parameters and walking capacities. RESULTS: TNN had a very marked effect on the level of spasticity and the range of motion in dorsiflexion (p<10(-3)). These changes resulted in better foot positioning when standing and walking (particularly in stance), which was perceived very favorably by the patients. There was a clear, patient-perceived improvement in activities performed when standing and walking (LL-FAS (p<0.01)), the global clinical impression of change (p<10(-3)) and the fear of falling (p=0.022) that was not revealed by conventional, objective measurements (New Functional Ambulation Classification, Rivermead Mobility Index). CONCLUSION: TNN is an effective treatment for post-stroke SEF; it is associated with a patient-reported improvement in standing and walking abilities during activities of daily living. Further research must now assess the long-term subjective efficacy of TNN.

Home enteral nutrition in children: an 11-year experience with 416 patients.

BACKGROUND & AIMS: We report our experience of paediatric home enteral nutrition, as there is little detailed evidence published. METHODS: All patients younger than 18 years commencing treatment between January 1990 and December 2000 were included in this retrospective study. RESULTS: The study covered 416 children and adolescents, corresponding to a total of 243,844 days of home enteral nutrition (HEN). The mean (+/-SD) age of patients commencing treatment was 5.4+/-5.3 years (range 0.1-17.8). Indications were digestive disorders in 35% of patients, neurological and muscular disorders in 35%, malignancy in 11%, failure to thrive in 8%, and miscellaneous ailments in 9%. Enteral feeding comprised commercially available paediatric industrial diets in 36%, adult-type diet in 35% and infant formulas in 29%. Children received enteral feeding by nasogastric tube (53%), or gastrostomy (41%). A mechanical pump was used in 98% of the patients. The mean duration of treatment was 595+/-719 days. CONCLUSIONS: HEN can be used while treating a large group of chronic diseases of children. It can be started very early in life and is often prolonged over several years.

Onabotulinumtoxin-A injection for disabling lower limb flexion in hemiplegic patients.

BACKGROUND: Hemiplegic patients with supraspinal spasticity can present with a flexor pattern at the hip and knee that hampers both passive and active functions. OBJECTIVE: To investigate the efficacy of OnabotulinumtoxinA injections on this flexor scheme. METHODS: This open-label observational study included eleven patients who had suffered a unilateral stroke or traumatic brain injury. All had impairment in the activities of daily living caused by severe hip and knee flexion. OnabotulinumtoxinA injections of 300-400U (total dose) were administered to the iliopsoas (iliacus) and knee flexors and, when necessary, to other muscles of the hip and knee. Evaluations were performed pre-treatment (weeks -4 to -8, and day 1) and post-treatment (week 10 and week 21): spasticity, range of motion, limb positioning, passive functions and pain. RESULTS: A modest improvement in hip and knee extension was observed, as evidenced by the Modified Ashworth Score and range of passive extension movements. Limb positioning was also improved. Clear benefits were found on passive functioning, including toileting, dressing and bed facilities, as well as pain levels. Active functions remained unchanged. More definite improvement was found in patients with severe difficulties. CONCLUSIONS: OnabotulinumtoxinA injection can contribute to reducing the consequences of disabling lower limb flexion.

Pilot assessment of a comfort scale in stroke patients.

INTRODUCTION: Comfort/discomfort (C/D) is an important factor of quality of life (QoL). Brain damage is a major source of discomfort. We developed a questionnaire for assessing C/D in daily living situations and for identifying the main causes of any discomfort and presented its pilot assessment in a population of stroke patients. METHODS: The scale is a questionnaire of the patient or caregiver that addresses (i) comfort/discomfort in 15 situations of daily living (including getting dressed, washing, lying in bed and sitting in a chair) and (ii) the roles of physical difficulties, psychological problems and a poorly adapted environment. We analysed its metrological qualities in a group of 62 stroke patients. RESULTS: For the patients, the most uncomfortable activities were eating, dressing the lower body, urine and faeces elimination and walking, and the most significant factors of discomfort were motor impairments, fatigue, limb stiffness, joint pain, depression and anxiety. The reliability was fair for the overall score and for each C/D item and moderate for the impact of impairments on comfort/discomfort. We also found fair internal consistency and convergent validity against measures of functional status, QoL and burden of care. Sensitivity to change over a 6-week period was modest. CONCLUSIONS: The scale can help to define difficulties in daily living situations and identify opportunities for intervention in stroke patients.

Construction and pilot assessment of the Lower Limb Function Assessment Scale.

BACKGROUND: Stroke often leads to upright standing and walking impairments. Clinical assessments do not sufficiently address ecological aspects and the patient's subjective evaluation of function. OBJECTIVE: To perform a pilot assessment of the psychometric properties of the Lower Limb-Function Assessment Scale (LL-FAS). METHODS: The LL-FAS includes 30 items assessing the patient's perception (in a questionnaire) and the examiner's perception (in a practical test) of upright standing and walking impairments and their impact on activities of daily living. We analyzed the LL-FAS's reliability, construct validity, internal consistency, predictive validity and feasibility. RESULTS: Thirty-five stroke patients were included. The scale's mean ± SD completion time was 25 ± 6 min. Intra-observer reliability was good to excellent (intraclass correlation coefficients (ICC >0.82). Interobserver reliability was moderate (0.67 < ICC < 0.9). The questionnaire and test items showed excellent construct validity for neuromotor disabilities (p < 0.05), postural ability (Postural Assessment Scale for Stroke; p < 10-5), severity of gait disorders (Gait Assessment and Intervention Tool; p < 10-3), walking ability (New Functional Ambulation Categories, 10 m walk test, Rivermead Mobility Index; p < 10-3) and functional level (Barthel Index; p < 10-3). Internal consistency (Cronbach-α >0.9) and predictive validity were excellent. CONCLUSIONS: The LL-FAS showed fair psychometric properties in this pilot study and may be of value for evaluating post-stroke lower limb impairment.

Growth hormone replacement therapy in patients with traumatic brain injury.

In patients with severe traumatic brain injury (TBI), a growth hormone deficiency (GHD) is frequent and may contribute to the cognitive sequelae and reduction in quality of life (QoL). Recent studies have suggested that GH replacement therapy (GHRT) can improve processing speed and memory. The aim of the study was to analyze the efficacy of GHRT on cognition, activities of daily living (ADL), and QoL and the factors that predicted and contributed to these effects. We included patients at least 1 year after their TBI and assessed pituitary functions (with stimulation tests), cognition (attention, memory, and executive function), participation in ADL and QoL. GHD was treated for at least 1 year in 23 patients, who were compared with 27 non-treated patients. Other deficiencies were also treated. Measurements were performed at baseline and 1 year later. An analysis of variance of the factors group and session (p ≤ 0.05) showed that most cognitive parameters had improved at 1 year (evidencing a session effect). A stronger effect of GHRT (i.e. a group x session interaction) was found for Rey Osterrieth complex figure recall and 2/6 domains in the QoL questionnaire ("personal" and "functional"). Trends (p ≤ 0.07) were also found for spatial orientation and immediate recall in the verbal memory test. Greatest improvements were associated with lower performance before treatment. The magnitude of the improvements in ADL and QoL was moderately correlated with the improvement in cognition. In conclusion, replacement therapy can improve cognition and QoL in patients with TBI who have GHD, especially in those with severe disabilities.

Lasting pituitary hormone deficiency after traumatic brain injury.

Pituitary deficiencies have been reported after traumatic brain injury (TBI) and may contribute to lasting cognitive disorders in this context. In a population of TBI patients with persistent cognitive and/or behavioral disorders, we sought to determine the prevalence of lasting pituitary deficiency and relationships with TBI severity, cognitive disorders, and impairments in activities of daily living (ADL). Fifty-five patients were included (mean age 36.1 years; 46 men) at least 1 year after TBI. They underwent a comprehensive evaluation of pituitary function (basic tests and stimulation), initial TBI severity, and long-term outcomes (cognitive performance, Glasgow Outcome Scale score, impact on ADL, and quality of life [QoL]). We used chi-squared and Mann-Whitney tests to probe for significant (p≤0.05) relationships between pituitary disorders and other parameters. Thirty-eight (69%) patients had at least one pituitary hormone deficiency. Growth hormone deficiency was more prevalent (severe: 40.0%; partial: 23.6%) than corticotropin (27.3%) or thyrotropin (21.8%) deficiencies. Other deficiencies were rare. Growth hormone deficiency was associated with attention and verbal memory disorders and reduced involvement in ADL. We did not find any relationship between pituitary deficiency and the TBI's initial severity. In a multivariate analysis, the TBI severity was introduced as a first factor, and pituitary deficits as a secondary factor for explaining the late outcome (ADL and QoL). In conclusion, TBI patients with cognitive sequelae must undergo pituitary screening because growth hormone, corticotropin, and thyrotropin deficits are particularly common and can adversely affect ADL and reduce QoL.

Communication in conversation in stroke patients.

In stroke patients, it has been suggested that communication disorders could result from lexical and syntactic disorders in left hemisphere lesions and from pragmatics problems in right lesions. However, we have little information on patient behaviour in dyadic communication, especially in conversation. Here, we analyzed the various processes participating in communication difficulties at the rehabilitation phase (1-6 months) post-stroke, in order to define the main mechanisms of verbal and non-verbal communication (VC, NVC) disorders and their relationship with aphasic disorders. Sixty-three patients were recruited, who belonged to six groups, with left or right cortico-sub-cortical (L-CSC, R-CSC) or sub-cortical (L-SC, R-SC), frontal (Fro) or posterior fossa (PF) lesions. They were compared with an equivalent control group (gender, age, education level). We used the Lille Communication Test, which comprises three parts: participation to communication (greeting, attention, engagement), verbal communication (verbal comprehension, speech outflow, intelligibility, word production, syntax, verbal pragmatics and verbal feedback) and non-verbal communication (understanding gestures, affective expressivity, producing gestures, pragmatics and feedback). We also used the Functional Communication Profile and the Boston Diagnostic Aphasia Examination (BDAE). Decrease in participation was found in L-CSC, R-CSC and Fro patients. Verbal communication was essentially disrupted in L-SCS and L-SC groups, including by verbal pragmatic disorders, and to a lesser degree in frontal patients. Nonverbal communication was mainly affected in R-CSC patients, especially by pragmatic difficulties. L-CSC patients showed an increase in gesture production, compensating for aphasia. In conclusion, communication disorders were relatively complex and could not be summarised by syntactical and lexical difficulties in left stroke and pragmatic problems in right stroke. The former also showed severe verbal pragmatic difficulties. Frontal stroke also resulted in evident verbal and non-verbal disorders.

Dramatic changes in home-based enteral nutrition practices in children during an 11-year period.

OBJECTIVES: Experience with pediatric home-based enteral nutrition (HEN), in particular series including children only, has been reported only rarely. We investigated the evolution of pediatric HEN activity during an 11-year period. METHODS: All patients aged 17 years or younger who started HEN between January 1990 and December 2000 were included in this retrospective study. RESULTS: The annual number of patients treated with HEN increased dramatically from 16 in 1990 to 200 in 2000, with more than 65 new patients every year since 1999 (P < 0.0001). The mean age at the commencement of HEN decreased from 6.2 +/- 1.4 (SEM) to 4.8 +/- 0.7 years (P = 0.006). The use of nasogastric tubes decreased from 63% in 1990 to 35% in 1998 (P = 0.009), and the use of gastrostomy increased from 50% to 60% from 1994 onward. The proportion of patients with digestive diseases commencing HEN in each year decreased from more than 40% before 1996 to less than 32% in 2000 (P = 0.009). Commercially manufactured pediatric diets were used increasingly (P = 0.0006). CONCLUSIONS: The evolution of HEN was marked by changes in the population treated and the modes of treatment after the emergence of gastrostomy and commercial diets. This justified the creation of a multidisciplinary, pediatric artificial nutrition unit.