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

Behavioural changes are the main cause of difficulties in interpersonal relationships and social integration among traumatic brain injury (TBI) patients. The Société française de médecine physique et réadaptation (SOFMER) decided to develop recommendations for the treatment and care provision for these problem under the auspices of the French health authority, the Haute Autorité de la santé (HAS). Assessment of behaviour is essential to describe, understand and define situations, assess any change and suggest lines for intervention. The relationship of these behavioural changes with the brain lesion is likewise of crucial importance in legal and forensic expertise.

AIMS

Using a literature review and expert opinions, the aim was to define the optimal conditions for the collection of data on behavioural changes in individuals having sustained brain trauma, to identify the situations in which they arise, to review the instruments available, and to suggest lines of intervention.

METHODS

A literature search identified 981 articles, among which 122 on the target subject were selected and analysed in detail and confronted with the experience of professionals and user representatives. A first draft of the recommendations was produced by the working group, and then submitted to a review group for opinions and complements.

RESULTS

The literature on this subject is heterogeneous, and presents low levels of evidence. No article enabled the development of recommendations above the "expert opinion" level. After prior clarification of the aims of the evaluation, it is recommended first to carefully describe the changes in behaviour, from patient and third-person narratives, and where possible from direct observations. The information enabling the description of the phenomena occurring should be collected by different individuals (multi-source evaluation): the patient, his or her close circle, and professionals with different training backgrounds (multidisciplinary evaluation). The analysis of triggering or associated factors requires an assessment of cognitive functions and any neurological pathology (seizures). After confrontation and synthesis, the information should be completed using one or several behavioural scales, which provide objectivity and reproducibility. The main generic and specific scales are presented, with their advantages, drawbacks and validation references. The group did not wish to recommend any one of them in particular.

CONCLUSION

The evaluation of behavioural changes is essential, since without it a therapeutic strategy and appropriate orientation cannot be implemented. The emphasis should be put on contextualised, multi-source and multidisciplinary evaluation, including validated behavioural scales. In this area, nevertheless, evaluation is still restricted by several methodological limitations. Further research is needed to improve the standardisation of data collection and the psychometric properties of the instruments. A European harmonisation of these procedures is also greatly needed.

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

Participation in community life is a major challenge for most people with psychiatric and/or cognitive disabilities. Current assessments of participation lack a theoretical basis. However, the new International Classification of Functioning, Disability and Health (ICF) provides a relevant framework.

AIMS

The present study used an ICF-derived assessment tool to activity limitations and participation restrictions in two groups of participants with disabilities linked to schizophrenia or traumatic brain injury respectively.

METHODS

Twenty-six items (related to six ICF sections) were selected by reviewing the literature and gathering the clinician's opinions and representatives of patient associations. These items, yielded an ordinal rating of activity limitations, participation restrictions and contextual factors (social support, attitudes and, systems & politics). Special attention was paid to contextual and environmental factors. The final checklist (called the Grid for Measurements of Activity and Participation, G-MAP) was administered to 16 participants with traumatic brain injury (the TBI group) and 15 participants with schizophrenic disorders (the SD group). Psychometric assessments of cognition and, neurobehavioural, psychological and psychosocial functioning were also performed.

RESULTS

The internal consistencies for activity limitations (Cronbach's alpha coefficient=0.89) and participation restriction (Cronbach's alpha coefficient=0.89) were satisfactory. We did not observe any significant differences between the two groups in terms of the psychometric test results. The G-MAP scores demonstrated that the two groups were confronted with the same limitations in self care, domestic life, leisure and community life (i.e., the intergroup differences were not statistically significant in Mann-Whitney tests). However, interpersonal relationships and economic and social productivity appeared to be more severely limited in the SD group than in the TBI group. Similarly, participation restrictions in domestic life, interpersonal relationships and economic and social productivity were more severe in the SD group than in the TBI group.

CONCLUSION

G-MAP is a useful, feasible, relevant tool for performing a detailed, individualized assessment of participation restrictions in people with psychiatric and/or cognitive disabilities.

[The neurobehavioral rating scale-revised: assessment of concurrent validity]

Cognitive and behavioral impairment are a major source of disability in daily living of patients with traumatic brain injury (TBI). The Neurobehavioral Rating Scale-Revised (NRS-R) is a short, easy-to administer interview tool developed to improve assessment by clinicians. Data are available on its criterion validity and reliability, but the concurrent validity of the French NRS-R was not yet documented.

OBJECTIVE

To assess the concurrent validity of the NRS-R with current psychometric tests.

METHOD

One hundred and four patients with TBI enrolled in a community adjustment program underwent concurrent examination with the NRS-R, cognitive tests assessing memory, attention, and executive functions, and scales of anxiety (STAI) and depressive mood (CES-D). Intercorrelations were undertaken between these variables and the five factors of the NRS-R: F1, intentional behavior; F2, lowered emotional state; F3, survival-oriented behaviour/hightened emotional state; F4, arousal state; and F5, language. Patients were 82 men and 22 women, the mean age was 28.5 years, and 70% had severe TBI (Glasgow coma score [GCS] below 8 on admission). They were assessed 52 months on average after their injury.

RESULTS

Factor F1 was correlated with results on the GCS (P<0.05), the Tower of London test (TL, P<0.01), the Trail Making Test (TMT, P<0.01), divided attention (DA) and inhibition (IN) subscales of the Zimmermann and Fimm's Attention battery (TEA) (P<0.01) and reverse digit span (DS, P<0.05). Factor F2 was positively related to age at injury, time since injury (TSI) (P<0.05) and CESD and STAI scores (P<0.001). Factor F3 was related to DA (P<0.01) TL scores and TSI (P<0.05). Factor F4 was related to TL, TMT, DA, flexibility, DS (P<0.05), TSI, duration of post-traumatic amnesia, CES-D score (P<0.05) and STAI scores (P<0.01). Factor F5 was related to GCS, DA (P<0.05), and reaction time on the subscales IN and Go/nogo (GO) of the TEA battery (P<0.01). The NRS-R total score was related to CESD, STAI scores, TMT score, DA (P<0.01) and TL score, IN and GO scores and TSI (P<0.05).

DISCUSSION

As McCauley et al found with the English version of the NRS-R, significant relationships were found between NRS-R factor scores, cognitive tests and emotional scales. Relationships were also found between factor scores and indicators of injury severity and time since injury. These data suggest fair concurrent validity of the NRS-R.

[Botulinum toxin A and musculoskeletal pain]

INTRODUCTION

Relaxant muscle properties and pain relieve effectiveness in neurological spasmodic disorders of botulinum toxin A (BTXA) suggested its relevance to relieve musculoskeletal pain. The aim of this article was to collect literature data and to assess the different analgesia indications of BTXA proposed in the treatment of musculoskeletal pains.

METHOD

The international literature was carried out with the Medline data bank using keywords toxin and pain. Only clinical trials have been analysed.

RESULTS

Three hundred and seventeen articles were collected and 12 clinical trials were retained. They are focused on 4 chronic diseases, neck pain, tennis elbow, Piriformis syndrome and low back pain. Results of the 6 chronic neck pain studies are contradictory and emphasize the difficulty to display a satisfactory analgesia effect of BTXA in this indication. Results of the studies concerning other indications (tennis elbow, Piriformis syndrome and low back pain) seem to be more effective and clinically pertinent.

DISCUSSION

Analgesia BTXA effect seems to be conditioned by the presence of an objective muscular spasm or stringy disease inducing musculoskeletal pain.

CONCLUSION

The first data concerning use of BTXA to treat musculoskeletal pains are few and are worth specifying by other studies.

[Botulinum toxin and traumatic brain injury]

Botulinum toxin is a successful focal spasticity therapy. The aim of this article is to study the data of the literature concerning its utilisation in traumatic brain injured patients, whom motor and tonus disturbances are polymorphic, in their clinical presentation as well as in their evolution. Although there are few studies concerning its utilisation in such patients, none of them being controlled, its use seems interesting in focal spasticity treatment. It can contribute to improve functional abilities and comfort for these patients.

[Life satisfaction and psychosocial outcome in severe traumatic brain injuries in Aquitaine]

OBJECTIVE

To assess late outcome and satisfaction of life of patients with severe traumatic brain injury (TBI) patients who received inpatient rehabilitation in Aquitaine.

DESIGN AND PATIENTS

Seventy-nine consecutive patients out of the 158 who were hospitalized for rehabilitation in 1993 were asked for in 2000 by a phone interview including standardised scales and free talk as well.

RESULTS

The results showed that nine years on average after their injury, 65 to 85% of patients were independent for daily living, whereas 35 to 55% only were independent in social life. Most of them were satisfied with their autonomy (67%), family life (66%) and financial status (41%), but they were dissatisfied with leisure (36%), vocational adjustment (28%) and sexual life (32%).

CONCLUSION

Return to work, leisure and sexuality are major parameters of satisfaction of life after a severe TBI, and should be emphasized in goal-directed rehabilitation programs.

Satisfaction of life and late psycho-social outcome after severe brain injury: a nine-year follow-up study in Aquitaine

In view of assessing their late outcome and satisfaction of life, 79 out of 158 severe traumatic brain injury (STBI) patients who received inpatient rehabilitation in Aquitaine in 1993 were followed by phone interview. Results showed that 9 years on average after their injury, 65 to 85% of these patients were independent for daily living, whereas 35 to 55% only were independent in social life. Most of the patients were satisfied with their autonomy (67%), family life (66%) and financial status (41%), but they were dissatisfied with leisures (36%), vocational adjustment (28%) and sexual life (32%). Satisfaction of life was mostly related to age, gender, physical autonomy, need of help because of cognitive impairment and functional outcome as assessed by the Glasgow Outcome Scale. Severe traumatic brain injury (STBI) stands in industrialised countries as a major Public Health problem and a dreadful human drama for the patients, their families and the community [2]. A great number of STBI patients survive with severe disability, most of them being young adults. The most severely impaired may live only with their parents or in high-cost nursing homes. From a psychological point of view, STBI causes a total and sudden breakdown of the mental states, personality and conditions of life. Life plans and projects are definitively disrupted, satisfaction of life is deeply changed. Rehabilitation aims at improving functional outcome of persons with STBI, and at improving their overall quality of life. Planning for rehabilitation and re-entry into community of STBI patients need to be provided with precise data on their late outcome and disability level. Despite that the concepts of quality and satisfaction of life are difficult to define and moreover to assess, these are also major factors to take into account. The aims of the present study were to assess the late psycho-social outcome of patients hospitalized in Aquitaine for rehabilitation of a STBI 7 to 10 years after their injury, and to ask for their satisfaction of life and subjective feeling of quality of life.

[Reiterated intravesical instillation of capsaicin in neurogenic detrusor hyperreflexia: a 5-years experience of 100 instillations]

INTRODUCTION

Capsaicin is a topic and specific C-fiber afferent neurotoxic. After spinal-cord injury, C-fiber afferent proliferate in the bladder mucosae and are involving in detrusor hyperreflexia

AIM OF THE STUDY

To investigate middle-term efficacy and tolerance of intravesical instillation of capsaïcin in spinal-cord injured patients presenting severe urinary incontinence refractory to usual therapy due to detrusor hyperreflexia.

METHODS

Thirty patients receveid a first intravesical instillation of 1mMol/L Capsaïcin solution in 30% alcohol. The efficacy (voiding diary, pads, quality of life, maximum cystometric capacity, maximum detrusor pressure, first and normal desire to void) and tolerance were evaluated before, 1 month and 3 months after each instillation, completed by anual cystoscopy. In patients who responded favorably to this instillation, repeated instillations were proposed when symptoms recurred.

RESULTS

25 patients (83.3%) were improved after the initial instillation (decrease of incontinence-frequency-urgency, best quality of life, rise on maximal cystometric capacity), since the 15(th) day and for 3.2 months. 76 reiterative instillations were performed in 22 patients (2 to 9 instillations per patient). 91.2% of them remained successfull, during an average period of 4.2 months. It does not appear loss of benefits after iterative instillations. Transient and moderate adverse effects followed 86% and 79% of the first and reiterated instillation (exacerbation of incontinence, supra-pubic pain). Two patients have presented a begnin and transient inflammatory cystitis after reiterated instillation.

DISCUSSION-CONCLUSION

Intravesical instillation of capsaïcin are an effective treatment for incontinence and associated symptoms caused by neurogenic detrusor hyperactivity. Propositions to improve immediate tolerance are debated.

The neurobehavioural rating scale-revised: sensitivity and validity in closed head injury assessment

OBJECTIVES

To investigate the factor structure and psychometric properties of the neurobehavioural rating scale-revised (NRS-R) and to determine its usefulness in clinical trials.

METHODS

A consecutive series of patients sustaining severe closed head injury were evacuated to one of 11 large regional North American trauma centres and entered into a randomised, phase III, multicentre clinical trial investigating the therapeutic use of moderate hypothermia. Acute care personnel were blinded to outcome and outcome personnel were blinded to treatment condition. The Glasgow outcome scale (GOS) was the primary outcome measure. Secondary outcome measures included the disability rating scale (DRS) and the NRS-R.

RESULTS

Exploratory factor analysis of NRS-R data collected at 6 months after injury (n=210) resulted in a five factor model including: (1) executive/cognition, (2) positive symptoms, (3) negative symptoms, (4) mood/affect, and (5) oral/motor. These factors showed acceptable internal consistency (0.62 to 0.88), low to moderate interfactor correlations (0.19 to 0.61), and discriminated well between GOS defined groups. Factor validity was demonstrated by significant correlations with specific neuropsychological domains. Significant change was measured from 3 to 6 months after injury for the total score (sum of all 29 item ratings) and all factor scores except mood/affect and positive symptoms. The total score and all factor scores correlated significantly with concurrent GOS and DRS scores.

CONCLUSIONS

The NRS-R is well suited as a secondary outcome measure for clinical trials as its completion rate exceeds that of neuropsychological assessment and it provides important neurobehavioural information complementary to that provided by global outcome and neuropsychological measures.

Rehabilitation of postural disturbances of hemiplegic patients by using trunk control retraining during exploratory exercises

OBJECTIVE

To assess use of the Bon Saint Côme device for axial postural rehabilitation in hemiplegic patients, a technique based on voluntary trunk control during exploratory retraining.

DESIGN

A 3-month randomized controlled trial.

SETTING

A public neurorehabilitation center.

PATIENTS

Twenty consecutive hemiplegic patients with axial postural disturbance resulting from recent stroke were randomly assigned to a device group (DG) or control group (CG). The 2 groups of 10 patients were similar.

INTERVENTION

For 1 month, the DG patients followed an experimental program for 1 hour daily and conventional neurorehabilitation for 1 hour daily, whereas CG patients had conventional neurorehabilitation for 2 hours daily. For the next 2 months, all 20 patients had conventional neurorehabilitation for 2 hours daily.

MAIN OUTCOME MEASURES

Patients were assessed on days 0, 30, and 90 by using a battery of postural tests, gait evaluation, the Bells neglect test, and the FIM instrument.

RESULTS

On day 30, postural and neglect tests improved significantly more in DG than in CG. The benefit remained at day 90. Gait improved earlier in DG than in CG. FIM scores improved equally.

CONCLUSIONS

Voluntary trunk control retraining during spatial exploration with the Bon Saint Côme device appears to be a useful approach for rehabilitation of postural disorders in hemiplegic patients. Treatments designed to improve spatial cognition deficits probably enhance postural disorder recovery in hemiplegia.

Early rehabilitation after severe brain injury: a French perspective

Severely brain-injured patients often suffer from disabilities and psycho-social handicaps. Early rehabilitation aims at improving their motor and functional recovery while preventing or treating complications as soon as possible. In this review we look at some issues encountered in early rehabilitation. We illustrate our discussion with data from 876 French traumatic brain injury patients admitted over the course of 1 year at 18 rehabilitation units that were asked for details of their current practice. Preservation of vital functions follows standardized protocols, but rehabilitation is more controversial. Few controlled trials are available. Good agreement exists among clinicians about prevention of orthopedic complications and treatment for spasticity. However, little consensus exists concerning treatment of non-pyramidal hypertonia and spasms or about procedures that can be undertaken to improve arousal from a coma or vegetative state. Finally, we look at other specific issues of early rehabilitation, namely prediction of outcome, psychological difficulties of patients and their families, efficiency and cost-effectiveness.

Fluoxetine in early poststroke depression: a double-blind placebo-controlled study

BACKGROUND AND PURPOSE

Early poststroke depression (PSD) is a frequent and specific entity that impairs the rehabilitation and functional recovery of hemiplegic patients. This trial was designed to study the efficacy and tolerance of fluoxetine (FLX) in the treatment of early PSD.

METHODS

This was a multicenter, double-blind, placebo-controlled study. Recent hemiplegic patients (<3 months) suffering from major depressive disorder (determined by International Classification of Diseases, 10th Revision, and Montgomery-Asberg Depression Rating Scale [MADRS] >19) were randomized to receive either 20 mg/d fluoxetine (FLX) or placebo for 6 weeks. Patients were evaluated by use of the Motricity Index, Mini-Mental State Examination, Functional Independence Measure, and MADRS. Statistical analysis was performed by using an intent-to-treat approach comparing the 2 groups at day 0 (baseline) and days 15, 30, and 45 (end point).

RESULTS

Of 121 patients screened, 31 were included in the study, 16 in the FLX group and 15 in the placebo group. There were no significant differences in baseline characteristics among the 2 groups. The FLX-treated patients compared with placebo-treated patients demonstrated significant improvement in mean MADRS scores at end point (11.8+/-6. 7 [mean+/-SD] versus 18.7+/-10.0, respectively; P=0.05). FLX-treated patients compared with placebo-treated patients also demonstrated greater response rate (62.5% versus 33.3%, respectively) and greater mean decrease of MADRS (16.6 versus 8.4, respectively; P=0.02). There were no differences in motor, cognitive, or functional improvement and no significant side effects after FLX treatment, except for a patient with a moderate and transient increase of transaminases.

CONCLUSIONS

FLX is an efficacious and well-tolerated treatment for early PSD. Further research is needed to evaluate the efficacy and safety of long-term treatment in this population.

Capsaicin and neurogenic detrusor hyperreflexia: a double-blind placebo-controlled study in 20 patients with spinal cord lesions

The aim of this study was to investigate the efficacy and tolerance of capsaicin, a neurotoxin for C-fiber afferents, applied intravesically in the treatment of detrusor hyperreflexia. Eleven male and nine female patients who had spinal cord lesions caused by multiple sclerosis (12) or trauma (eight) resulting in detrusor hyperreflexia with urge incontinence and pollakiuria were randomized to receive one intravesical instillation of either 30 mg capsaicin in 100 ml 30% ethanol or 100 ml 30% ethanol alone. The patients were evaluated clinically (voiding diary) and urodynamically (maximum cystometric capacity, maximum detrusor pressure, first and normal desire to void) before and 30 days after the instillation. On day 30, the 10 patients who received capsaicin had significant decreases in 24-h voiding frequency from 9.3+/-6.1 to 6.7+/-3.8 (P=0.016) and leakages from 3.9+/-1.6 to 0.6+/-0.8 (P=0.0008); their maximum cystometric capacity increased from 169+/-68 to 299+/-96 ml (P=0.01) and maximum detrusor pressure decreased from 77+/-24 to 53+/-27 cm H2O. There were no significant changes in the control group. In seven subjects in each group, instillation triggered immediate side effects (suprapubic pain, sensory urgency, flushes, hematuria, autonomic hyperreflexia) that resolved within 2 weeks. Intravesical capsaicin significantly improves clinical and urodynamic parameters of detrusor hyperreflexia in spinal cord-injured patients. Side effects are frequent, tolerable, and identical to those induced by 30% ethanol alone.

Assessment of neuropsychologic impairments after head injury: interrater reliability and factorial and criterion validity of the Neurobehavioral Rating Scale-Revised

OBJECTIVE

To study interrater reliability and factorial and criterion validity of the Neurobehavioral Rating Scale-Revised (NRS-R).

DESIGN

Validity study on persons with traumatic brain injury (TBI) and test-retest reliability study on a randomly selected subset of patients. Factor analyses, kappa statistics, intraclass correlation coefficients, and Cronbach's alphas were used.

SETTING

Inpatients from 15 French hospitals, mainly rehabilitation units. Other recruitment sites included a neurology hospital unit and a psychiatry hospital specifically devoted to TBI rehabilitation.

PATIENTS

Two hundred eighty-six TBI patients ages 16 to 70 years (convenience sample).

RESULTS

For the reliability study, the average of percentages of agreement among the items was 74.3% and the average of kappa statistics was .40. Factor analyses disclosed a maximum likelihood extraction of 5 correlated factors (F), explaining 42.2% of total variance: (F1) deficits in intentional behavior and in memory, (F2) lowering of emotional state, (F3) emotional and behavioral hyperactivation, (F4) lowering of arousal state and of attention, and (F5) language and speech problems. Results support the criterion validity of the factors. Reliability of the factor scores and internal consistencies of factors were very good.

CONCLUSIONS

Results describe some important properties of the NRS-R and, through an understanding of its underlying structure and relationships with the patients' clinical characteristics, contribute to the conceptual framework of neuropsychologic impairments after TBI.

Critical illness polyneuropathy. A 2-year follow-up study in 19 severe cases

Critical illness polyneuropathy (CIP) is a reported cause of varying degrees of neuromuscular weakness in patients with multiple organ failure. Little is known concerning predictive factors of neurological recovery. The critical care conditions, neurological explorations and 2-year clinical follow-up of 19 patients who suffered from severe forms (quadriplegia or quadriparesis) of CIP were analyzed. Characteristics of patients who recovered clinically were compared with those of patients who did not. Two patients died within 2 months, 11 recovered completely, 4 remained quadriplegic and 2 remained quadriparetic. All patients suffered from sepsis, multiple organ dysfunction syndrome and a catabolic state before the onset of CIP. Outcome appears difficult to predict with clinical or electrophysiological data. Three parameters were significantly correlated with poor recovery: longer length of stay in the critical care unit, longer duration of sepsis and greater body weight loss. A relationship seems to exist between the severity of CIP and that of sepsis and its associated hypercatabolism. The favorable outcome usually attributed to CIP must be reconsidered. The authors recommend aggressive measures against sepsis to limit CIP and its sequelae.

Rehabilitation after traumatic brain injury in adults

PURPOSE

Traumatic brain injury (TBI) stands as a major public health problem and one of the most important challenges for neurological rehabilitation. This review discusses advances that have occurred in the past 10 years in rehabilitation after severe TBI in adults.

METHOD

First, theoretical concepts, goals of rehabilitation and organization of resources are reviewed. Then specific questions that arise in the rehabilitation of severe TBI patients are considered.

RESULTS

Three phases are distinguished in post-traumatic evolution. Acute rehabilitation takes place during coma and arousal states. Specific aims are to prevent orthopaedic and visceral complications, and to provide sensory stimulations with the hope of accelerating arousal. Secondly subacute (generally inpatient) rehabilitation is designed to facilitate and accelerate recovery of impairments, and to compensate for disabilities. Motility, cognition, behaviour, personality and affect should be simultaneously addressed in an holistic approach. Physical as well as psychological independence and self-awareness are the major goals to emphasize. A third, post-acute rehabilitation phase includes outpatient therapy for achieving physical, domestic and social independence, reduction of handicaps and re-entry into the community.

CONCLUSIONS

Problems with returning home, obtaining financial independence, driving, returning to work, participating in social relationships and leisure activities, and the importance of psychosocial adjustment and self-acceptance, are outlined. Questions about economic aspects and rehabilitation in the future are addressed.

The effects of capsaicin on the neurogenic hyperreflexic detrusor. A double blind placebo controlled study in patients with spinal cord disease. Preliminary results

PURPOSE

Several recent open studies have provided encouraging results as to the efficacy of intravesical installations of capsaicin for neurogenic hyperreflectivity. The present trial was performed to verify these results under controlled conditions. Intravesical installation of capsaicin represents a new therapeutic hope for the treatment of the neurogenic hyperrelfexic bladder.

METHOD

This randomized, double-blind study compared the results of the intravesical installation of 30 mg capsaicin in 100 ml of 30% alcohol (experimental group) with those of installing 100 ml 30% alcohol alone (control group). On day 0 and day 30, urodynamic and biopsic examinations were performed in all subjects of each group.

PATIENTS

All the subjects included in the study had a functionally disabling form of neurogenic hyperreflexic bladder resistant to the usual therapies. Cystoscopy and retrograde cystography were performed to exclude any patient who presented with a tumor-like lesion or had vesicoureteral reflux.

RESULTS

Twelve paraplegic of tetraplegic subjects, seven women and five men whose average age was 46, were included. Eight had multiple sclerosis, and four had sustained a traumatic spinal cord injury. The patients were randomly separated into two groups of six. Initially, there was no clinical or urodynamic differences in these groups. Installation immediately triggered side effects and during the first 7 days (suprapubic burning sensation, sensory urgency, hot flushes, autonomic hyperreflexia, hematuria) in five of the six subjects in both groups. Bladder biopsy revealed no significant deterioration. On day 30, there was improvement in all of the experimental-group of patients with significant regression of leakage (P = 0.002) and of sensory urgency (P = 0.01). Only one control subject had amelioration. Urodynamic examination showed a rise in bladder capacity from 172.5 to 312.3 ml in the experimental group, significantly greater (P = 0.03) than the rise from 129 to 175.3 ml observed in the control group.

CONCLUSION

This trial fully confirms the efficacy of intravesical installations of capsaicin, an efficacy obtained at the cost of nonnegligible side effects. An intermediate-term follow-up of this treatment will be necessary before considering more widespread use of this agent.

Ejaculatory stimulation, quality of semen and reproductive aspects in spinal cord injured men

this is a retrospective study of 39 male spinal cord injured patients who, over the last 5 years, have consulted us for ejaculatory dysfunction or infertility. All of these patients underwent at least two distinct sessions during which attempts were made to induce an ejaculation by vibratory stimulation, electric stimulation, or by using subcutaneous physostigmine. A semen analysis was performed each time that an ejaculate was obtained. By one or more of these techniques, 75% of these subjects were able to ejaculate. The level of the neurological lesion had a significant influence on the success rate. Likewise, the mode employed to produce an ejaculation influenced certain characteristics of the sperm collected (mean volume, percentage of motile forms), the best results being obtained by vibratory stimulation. Among the 10 couples who had consulted us for medically assisted reproduction, three pregnancies were obtained, two of which resulted in the birth of healthy children. Although the techniques of stimulation that we use allow ejaculation, the possibilities of reproduction remain limited in particular because of the difficulty in obtaining semen of adequate quality. Nevertheless, recent methods of micromanipulation of gametes should considerably improve the prognosis of the seminal insufficiencies in men with spinal cord injury.

Cognitive process in preclinical phase of dementia

Several recent prospective studies have demonstrated the existence of a preclinical stage of dementia, identifiable by neuropsychological assessment showing impairments with a great variety of cognitive tests. However, test scores are often colinear, largely because common cognitive components are involved in different tests; in spite of an apparent heterogeneity, it is still possible that a common cognitive component may be responsible for the deterioration shown in different tests in the preclinical phase. We studied the cognitive performances of 1159 elderly residents in the PAQUID (Personnes Agées quid) cohort, at a fixed lag time of 2 years before the clinical diagnosis of dementia. Seven neuropsychological tests were administered (Mini-Mental Status Examination, Benton Visual Retention Test, Wechsler Paired-Associates Test, Isaacs Set Test, Zazzo's Cancellation Task, Digit Symbol Substitution Test and Wechsler Similarities Test). Among the initially non-demented 1159 subjects, 25 developed a dementia 2 years later, of whom 16 were classified as cases of Alzheimer's disease. In order to dissect the multicolinearity of the tests we used a multivariate approach with principal component analysis (PCA). The patients' loading on each of the first four PCA factors were subsequently correlated with the risk of dementia and Alzheimer's disease 2 years later. The logistic regression with backward stepwise selected only the first factor as an independent predictor of dementia or Alzheimer's disease. Analysis shows that there are good reasons to suspect that the first PCA factor represents a general factor corresponding to aspects of control in the tasks used. Our results therefore seem to show that preclinical deficits in dementia and Alzheimer's disease reflect the deterioration of a general cognitive factor, which may be interpreted as the disturbance of central, control processes.

Long-term neuropsychological outcome and loss of social autonomy after traumatic brain injury

OBJECTIVE

To assess which social activities were still impaired 5 years after a traumatic brain injury (TBI) in adults, and which neuropsychological impairments were associated with this loss of social autonomy.

DESIGN

Cross-sectional study of 79 patients selected from the follow-up cohort of an epidemiologic survey of 2,116 TBI patients.

SETTING

The present study was of ambulatory patients seen at hospital or at their homes. The inception cohort was from the trauma center of a university hospital and from a general hospital that is representative of level II trauma centers in Aquitaine, France.

PATIENTS

Seventy-nine patients selected from a representative sample of 407 patients who were included in the 5-year follow-up study of the initial cohort (convenience sample).

MAIN OUTCOME MEASURES

Glasgow Outcome Scale (GOS) and loss of social autonomy as assessed by the European Brain Injury Society's European Head Injury Evaluation Chart; assessment of neurobehavioral impairments by means of the Neurobehavioral Rating Scale-Revised.

RESULTS

Up to 16 patients suffered disability for at least one social skill because of cognitive/behavioral reasons. Seven needed full-time supervision. Performing administrative tasks and financial management, writing letters and calculating, driving, planning the week, and using public transport were the most impaired social abilities. Loss of social autonomy was mainly observed in severely injured patients. Univariate analysis showed that mental fatigability, motor slowing, memory difficulties, and disorders of executive function were associated with low scores on the GOS, unemployment, and difficulties in shopping, using public transport, and performing financial management and administrative tasks.

CONCLUSION

Persistent impairments of executive functions and speed of psychomotor processing are major factors associated with loss of social autonomy and inability to return to work long after TBI in adults. Improving these impairments in concrete social situations represents a major challenge for cognitive rehabilitation.

Unilateral neglect syndrome rehabilitation by trunk rotation and scanning training

OBJECTIVE

Assessment of a new rehabilitation method for unilateral neglect syndrome (UNS), using a specific device (Bon Saint Come's device) that associates exploratory reconditioning with voluntary trunk rotation.

DESIGN

Study 1, randomized control trial during 2 months; study 2, nonrandomized control trial during 2 months.

SETTING

Neurorehabilitation units in private and public center.

PATIENTS

In study 1, 22 consecutive patients with UNS resulting from recent stroke (< 3 months) were randomly assigned to an Experimental Group (11 patients) or to a Control Group (11 patients). The 2 groups were very similar in terms of general and neurological data. In study 2, 5 consecutive patients with chronic UNS resulting from an old stroke (> 6 months) showing the same characteristics were included.

INTERVENTION

In study 1, patients in Group E followed the experimental program 1 hour a day for 1 month (20 hours) and Group C followed usual neurorehabilitation during the same time. In study 2, every patient followed the experimental program 1 hour a day for 1 month (20 hours).

MAIN OUTCOME MEASURES

Assessment in both studies was done at day 0, day 30, and day 60 using a battery of UNS tests (Albert, Scheckenberg, bell) and an activities of daily living (ADL) test (the Functional Independence Measure [FIM]). Mean scores of each test were compared between the 2 groups with the Wilcoxon nonparametric test.

RESULTS

In study 1 all UNS test results and the FIM improved significantly more in Group E than in Group C. In Group E, UNS disappeared in 5 patients and improved in 6. In Group C, UNS disappeared in 1 patient, improved in 4, and was unchanged in 6. In Study 2, UNS remitted in 2 patients, improved in 2 patients, and was unchanged in 1.

CONCLUSION

The Bon Saint Come method seems to significantly improve recent and chronic UNS, as well as ADL function. These encouraging results could have resulted from a synergistic effect of spatial reconditioning and voluntary trunk rotation. It must be assessed by a new study with more patients.

Cognitive predictors of dementia in elderly community residents

Detection of subjects with a high risk of developing dementia is a major goal of epidemiological research. Among the potential predictors, minor cognitive impairments detected by psychometric methods could be important precursors. A total of 2,726 elderly nondemented subjects, aged 65 and over, randomly selected from the general population of Gironde (south-western France) were followed up for 3 years. During this time, 84 developed an incident dementia, diagnosed as Alzheimer's disease (AD) in 59. The relationships between cognitive performance (Mini Mental State Examination, Benton Visual Retention Test and Isaacs Set Test) measured at the baseline screening of the cohort and the risk of dementia or AD were studied with a discrete Cox proportional hazard model. After adjustment for age and educational level, the three test scores remained strongly related to the risk of dementia or AD. Psychometric performance can be used to screen subjects at risk of developing dementia or AD and allow pharmacological intervention at an early stage.

A randomised, double blind, placebo controlled trial of botulinum toxin in the treatment of spastic foot in hemiparetic patients

OBJECTIVE

To confirm the apparent effectiveness of botulinum toxin (BTX) in hemiparetic patients with ankle plantar flexors and foot invertor spasticity.

METHODS

Twenty three hemiparetic patients with spasticity of the ankle plantar flexors and foot invertors were included in a randomised double blind, placebo controlled study with BTX. Patients were examined on days 0, 30, 90, and 120 and received one injection of BTX and one of placebo in a random order at day 0 and day 90.

RESULTS

Patients reported a clear subjective improvement in foot spasticity after BTX (P = 0.0014) but not after placebo. Significant changes were noted in Ashworth scale values for ankle extensors (P < 0.0001) and invertors (P = 0.0002), and for active ankle dorsiflexion (P = 0.0001). Gait velocity was slightly but not significantly (P = 0.0731) improved after BTX injections. The severity of spasticity did not modify treatment efficacy, but BTX was less effective in patients with longer duration of spasticity (P = 0.0081).

CONCLUSION

The efficacy of BTX injections in the treatment of spastic foot suggests that BTX may be particularly useful during the first year after a stroke.

Visuo-spatial attention and psychomotor performance in elderly community residents: effects of age, gender, and education

In cross-sectional analysis of 1,799 subjects of the Paquid Research Program, an epidemiological study on brain aging conducted in the Bordeaux area (France), we have studied the effects of age, gender, and education level on psychometric tests requiring visuo-spatial focused attention and psychomotor performance. Although previous studies suggest that normal aging produces no significant change in focused attention, we did observe lower attentional abilities and lower speed of execution with increasing age. Female gender and low education level were also related to poorer attention and psychomotor performance. As the effects of these individual factors are difficult to disentangle from each other on the small samples of subjects used in group studies, epidemiological surveys seem useful to provide a better understanding of the neuropsychology of aging.

Severe axonal polyneuropathy with onset in the postpartum period

We report two patients who presented severe polyneuropathy in the postpartum period. Electrophysiological studies evidenced an axonal process which was associated with proximal demyelination in the second patient. In both cases, a peripheral nerve biopsy showed severe axonal Wallerian-like degeneration and no feature of demyelination. The first patient had a dramatic loss of myelinated fibres, and severe disability persisted for several months. These two patients are different from cases of acute or chronic inflammatory demyelinating polyradiculoneuropathy previously reported in relation with pregnancy.

Self-reported memory complaints and memory performance in elderly French community residents: results of the PAQUID Research Program

An epidemiological survey of self-reported memory complaints and memory performance [assessed with Benton's visual-retention test (BVRT) and the Wechsler paired-associates test (WPAT)] was undertaken in a community sample of 2,726 noninstitutionalized subjects aged 65 and over living in Gironde (southwestern France). A significant relationship was observed between the presence of self-reported memory problems and lower performance on the BVRT and the WPAT. However, beyond this relationship, there was significant discordance between the two evaluations, explained in part by the fact that the correlates of memory functioning were not related with similar strength to self reports and to actual performance. In general, females and subjects who scored above the depressive symptomatology threshold reported more problems, while lower performances were related to older age and low educational level. The discordance between self reports and actual performance may suggest anosognosia of mild memory deficits and could possibly be a predictor of future intellectual deterioration.

Occupation during life and memory performance in nondemented French elderly community residents

Using data obtained during the baseline screening of the PAQUID cohort, an epidemiologic study on brain aging conducted in the Bordeaux area of France, we studied the relationship between lifetime occupation and memory performance in visual recognition (Benton Visual Retention Test; BVRT) and verbal induced recall (Wechsler Paired Associates Test; WPAT) in 2,720 elderly community residents. Occupational category was strongly correlated with poor memory performance for both the BVRT and the WPAT. Independent of the educational level, the risk of having poor memory performance was two to three times greater for farmers, domestic service employees, and blue-collar workers than for professionals/managerials. Occupational category should be taken into account in future cross-national studies on brain aging.

[Parkinson disease and communication]

Communication abilities imply multifactorial analysis. These disorders in Parkinson's disease involve speech, graphism, functional and paraverbal gestures. The patient's isolation in a major form of disease is dramatic. Functional study requires an analysis of each factor; progress should be realized for an objective approach. With a therapeutic objective in view, the most impaired features, and the patients real situation and way of life must be evaluated. Some training measures are useful especially for social adjustment and motivational reinforcement.

Initial factors predicting functional performance in patients with traumatic tetraplegia

The authors present a prospective analysis of the functional outcome in 99 patients with traumatic tetraplegia consecutively admitted to the Pellegrin Hospital (University Hospital, Bordeaux, France). There was a 29% death rate. Eighteen months after injury, 33% of the patients were dependent (not able to perform activities of daily living without the presence of a helping individual), 38% were independent. Two predictors of independence (age and initial Yale Scale Score) were found by a statistical analysis of the course of the disorder.

Initial factors predicting survival in patients with a spinal cord injury

A study is presented of a prospective analysis of survival rates in 157 patients with spinal cord injury consecutively admitted to the Pellegrin Hospital (University Hospital, Bordeaux, France). There was a 20% death rate, occurring in the first three months after injury. Three independent predictors of survival in patients with spinal cord injuries (age, initial conscious level and respiratory assistance) were found by analysis of the course of the disorder.

Early prognostic factors for walking in spinal cord injuries

The authors present a prospective analysis with 1 year follow-up of about 157 consecutive spinal cord injured patients admitted to the Bordeaux CHU, over a 3 year period (1982-1985). They present a method of analysing the walking status recovery in patients with spinal cord injuries from the early factors recorded on initial clinical examination. Twenty eight per cent of all patients are 'functional walkers', 1 year after injury. Three early factors were selected: age; the level of injury; and the initial Yale Scale Score. Only the age and the initial Yale Scale Score are independent predictive factors, according to the Cox model. The authors present a model of walking status recovery, 1 year after the injury, predicted from age and the initial Yale Scale Score.

[Noncompressive myelopathy and dysglobulinemia. A fortuitous association? Discussion of 3 new cases]

Three new cases of myelopathy without compression associated with paraproteinemia are reported. The neurologic picture was that of spinal muscular atrophy in one case and chronic spinal combined sclerosis in two. The nature of the paraproteinemia is discussed: all three patients seem to have had benign monoclonal dysglobulinemia. One patient died from cardiovascular disease five years after onset, and another from complications related to decubitus seven years after onset. Postmortem examination was not possible in either case. Spinal muscular atrophy has been reported in certain carcinomas (lung, stomach, breast) and, less frequently, in macroglobulinemia. As benign dysglobulinemia is common after sixty, coincidental association cannot be outruled. However, data from the literature and the response to cancer chemotherapy in two patients suggest an original pathologic association. Recent demonstration of demyelinating neuropathies associated with benign paraproteinemia provide further evidence in support of such an association.

[Analysis and quantitative study of language disorders in lesions of the left thalamus: thalamic aphasia]

We have studied 5 patients having a language disturbance associated with a left thalamic lesion documented by computerized tomography. These patients were submitted to a french adaptation of the Boston Diagnostic Aphasia Examination, originally designed by Goodglass and Kaplan. A quantitative analysis of these language disturbances has shown that they are characterized by reduction of fluency, resembling that of dynamic aphasia, with impaired volume, tone and articulation of speech. There is also a difficulty at finding word categories. Perseverations are frequent while paraphasias are scarce, being then mostly incoherences. Comprehension is impaired, but only at a complex level. Reading and writing are inconsistently affected. This symptom-complex is coherent enough from case to case to be considered as a recognizable type of aphasia, and specially since it is invariably associated with a left thalamic lesion.

[Goodglass and Kaplan's test in patients with language difficulties due to thalamic lesions (author's transl)]

Two out of three patients with language difficulties from ischemic, tumoral, or hemorrhagic lesions of the left thalamus were studied by means of Goodglass and Kaplan's test. Results were compared to those obtained by using the same test in a patient with a hemorrhagic lesion in the posterior ramus of the left internal capsule, but no thalamic lesion. They demonstrate the autonomy of the clinical picture of "thalamic aphasia" as described in several cases reported in the published literature. The suggestion is made that the term, aphasia, can be applied to these cases as long as care is taken when defining them.

[Anatomical and clinical considerations in aphasia: the value of tomodensitometry (author's transl)]

Tomometric tests were carried out in 54 patients with a clinical picture of stabilized or regressive aphasia, some time after the initial episode. The correlation between clinical and topographic findings were satisfactory in 90 p. 100 of the cases. The frequency of lesions extending into several lobes (70 cases) and of multiple lesions is stressed. There is a significant relationship between the severity of the clinical findings during tomometric testing and the volume or multiplicity of the lesions. The progression of the disease after 6 months, as studied in 31 patients, was also related to the volume of the lesion, but was not influenced by the presence of diffuse atrophy, except where the disease was deteriorating. The value of tomometry in the study of aphasia involves 3 factors: precise clinical and lesional correlation, and the effect of the volume of the lesion on its initial severity and progression. In the future, tomometry should enable a correlative symptomatic study of aphasic disorders to be made.