The value of incorporating personally relevant stimuli into consciousness assessment with the Coma Recovery Scale – Revised: A pilot study

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

The natural history of Alzheimer disease: a longitudinal presymptomatic and symptomatic study of a familial cohort.

BACKGROUND: Knowledge of the evolution of cognitive deficits in Alzheimer disease is important for our understanding of disease progression. Previous reports, however, have either lacked detail or have not covered the presymptomatic stages. OBJECTIVE: To delineate the onset and progression of clinical and neuropsychological abnormalities in familial Alzheimer disease. METHODS: Nineteen subjects with familial Alzheimer disease underwent serial clinical and neuropsychological assessments. Eight of these had undergone presymptomatic assessments. The follow-up period was 1 to 10 years (mean, 5 years). The relative timing of the occurrence of 3 markers of disease onset and progression (onset of symptoms, Mini-Mental State Examination score < or = 24, and impaired scores on a range of neuropsychological tests) were compared using the binomial exact test. RESULTS: Neurological abnormalities were not prominent, although myoclonus appeared early in some. Mini-Mental State Examination score was not sensitive to early disease. Memory and general intelligence deficits appeared at an earlier stage, in some patients when presymptomatic. Perceptual, naming, and especially spelling skills were preserved to a late stage. CONCLUSION: Familial Alzheimer disease may have a long prodromal phase of several years with subtle deficits initially of general intelligence and memory, while spelling, naming, and perception are relatively preserved until a late stage

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After severe acquired brain injury some patients develop a prolonged disorder of consciousness (vegetative state or minimally conscious state), and as such cannot actively participate in neurorehabilitation. However, international opinion and recent research developments emphasize the need for involvement of rehabilitation medicine units in the care of these patients. The article presents recommendations for the care of adult patients with prolonged disorders of consciousness, which have been developed by a multidisciplinary working party, in order to promote good care, and identify areas for further improvements

Behavioural problems in the first year after Severe traumatic brain injury : a prospective multicentre study

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

VALIDITY, INTRA-RATER RELIABILITY AND NORMATIVE DATA OF THE NEUROFLEXOR™ DEVICE TO MEASURE SPASTICITY OF THE ANKLE PLANTAR FLEXORS AFTER STROKE

International audienceObjective: Quantification of lower limb spasticity after stroke and the differentiation of neural from passive muscle resistance remain key clinical challenges. The aim of this study was to validate the novel NeuroFlexor foot module, to assess the intrarater reliability of measurements and to identify normative cut-off values.Methods: Fifteen patients with chronic stroke with clinical history of spasticity and 18 healthy subjects were examined with the NeuroFlexor foot module at controlled velocities. Elastic, viscous and neural components of passive dorsiflexion resistance were quantified (in Newton, N). The neural component, reflecting stretch reflex mediated resistance, was validated against electromyography activity. A test-retest design with a 2-way random effects model permitted study of intra-rater reliability. Finally, data from 73 healthy subjects were used to establish cutoff values according to mean + 3 standard deviations and receiver operating characteristic curve analysis.Results: The neural component was higher in stroke patients, increased with stretch velocity and correlated with electromyography amplitude. Reliability was high for the neural component (intraclass correlation coefficient model 2.1 (ICC2,1) ≥ 0.903) and good for the elastic component (ICC2,1 ≥ 0.898). Cutoff values were identified, and all patients with neural component above the limit presented pathological electromyography amplitude (area under the curve (AUC) = 1.00, sensitivity = 100%, specificity = 100%).Conclusion: The NeuroFlexor may offer a clinically feasible and non-invasive way to objectively quantify lower limb spasticity. LAY ABSTRACTSpasticity is a sensorimotor impairment, which often occurs after stroke as well as after other injuries to the central nervous system. Spasticity is characterized by increased resistance to passive stretch of weak muscles due to increased reflex activity. Spasticity is currently measured clinically while the examiner passively stretches a muscle. However, the clinical method cannot differentiate resistance due to increased reflex activity from resistance due to muscle stiffness, which can develop over time in weakened muscles. The aim of this study was to evaluate the novel NeuroFlexor foot module, which was developed to quantify and distinguish nerve and muscle components of resistance during passive stretching of the lower limb muscles. By quantifying these factors, one can obtain more reliable information than the clinical examination allows. NeuroFlexor measurements in 15 patients in the chronic stage after stroke and 18 healthy individuals allowed the validity of the method to be evaluated by assessing the relationship with velocity of stretch and by simultaneously examining the reflex activity using surface electromyography. The reliability of NeuroFlexor measurements was studied by comparing repeated measurements. Finally, the study established normal NeuroFlexor values from 73 healthy individuals. The results suggest that the NeuroFlexor foot module may be a valid, reliable and easy-to-use objective method to quantify lower limb spasticity

Disorders of consciousness after severe traumatic brain injury : a Swedish-Icelandic study of incidence, outcomes and implications for optimizing care pathways

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&gt;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

Subacute complications during recovery from severe traumatic brain injury: frequency and associations with outcome

Subacute complications during recovery from severe traumatic brain injury: frequency and associations with 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. BM

Subacute complications during recovery from severe traumatic brain injury : frequency and associations with outcome

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 &gt;= 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