Pierre-Alain Joseph

Botulinum toxin treatment in neurological practice: how much does it really cost? A prospective cost-effectiveness study.

Botulinum toxin (BTA) is a safe and effective therapeutic tool for many neurological conditions but few studies have investigated its real cost in neurological practice. We evaluated the daily cost of botulinum toxin type A (BTA) treatment through a cost effectiveness analysis alongside a prospective study of BTA injections at a French University Hospital over a 2-year follow-up period. The data of 3,108 BTA injections performed in 870 adult patients presenting with dystonia, facial hemispasm, or spasticity were entered in the database. Patients were questioned at each visit about the subjective effectiveness of the previous injection. The daily cost of BTA treatment was calculated as the ratio of each session’s cost (including all additional costs) to the duration of subjective efficacy. The subjective rating of efficacy duration was 17.3xa0±xa07.7xa0weeks for facial hemispasm, 15.4xa0±xa07.7 for blepharospasm, 14.3xa0±xa06.7 for cervical dystonia, 14.5xa0±xa07.8 and 14.1xa0±xa07.4xa0weeks for upper and lower limb spasticity, respectively. The daily cost of BTA injections was 0.57xa0±xa00.20xa0€ for facial hemispasm, 0.95xa0±xa00.30xa0€ for blepharospasm, 2.85xa0±xa00.86xa0€ for cervical dystonia, 3.38xa0±xa01.49xa0€ and 3.62xa0±xa01.81xa0€ for upper and lower limb spasticity, respectively. When associated costs were considered, the daily cost of BTA injections was clearly increased (45–93%) in limb spasticity or rigidity but remained only modestly increased (15–37%) in other indications. These results obtained in a large cohort of patients show that BTA treatment has a low daily cost for a long-lasting effect, with a daily cost/benefit ratio that greatly depends on the indications.

The Behavioral and Cognitive Executive Disorders of Stroke: The GREFEX Study

Background Many studies have highlighted the high prevalence of executive disorders in stroke. However, major uncertainties remain due to use of variable and non-validated methods. The objectives of this study were: 1) to characterize the executive disorder profile in stroke using a standardized battery, validated diagnosis criteria of executive disorders and validated framework for the interpretation of neuropsychological data and 2) examine the sensitivity of the harmonization standards protocol proposed by the National Institute of Neurological Disorders and Stroke and Canadian Stroke Network (NINDS-CSN) for the diagnosis of Vascular Cognitive Impairment. Methods 237 patients (infarct: 57; cerebral hemorrhage: 54; ruptured aneurysm of the anterior communicating artery (ACoA): 80; cerebral venous thrombosis (CVT): 46) were examined by using the GREFEX battery. The patients’ test results were interpreted with a validated framework derived from normative data from 780 controls. Results Dysexecutive syndrome was observed in 88 (55.7%; 95%CI: 48–63.4) out of the 156 patients with full cognitive and behavioral data: 40 (45.5%) had combined behavioral and cognitive syndromes, 29 (33%) had a behavioral disorder alone and 19 (21.6%) had a cognitive syndrome alone. The dysexecutive profile was characterized by prominent impairments of initiation and generation in the cognitive domain and by hypoactivity with disinterest and anticipation loss in the behavioral domain. Cognitive impairment was more frequent (p = 0.014) in hemorrhage and behavioral disorders were more frequent (p = 0.004) in infarct and hemorrhage. The harmonization standards protocol underestimated (p = 0.007) executive disorders in CVT or ACoA. Conclusions This profile of executive disorders implies that the assessment should include both cognitive tests and a validated inventory for behavioral dysexecutive syndrome. Initial assessment may be performed with a short cognitive battery, such as the harmonization standards protocol. However, administration of a full cognitive battery is required in selected patients.

Do patients with traumatic brain injury learn a route in the same way in real and virtual environments

An increasing number of studies address the use of virtual environments (VE) in the cognitive assessment of spatial abilities. However, the differences between learning in a VE and a real environment (RE) remain controversial. Purpose: To compare the topographical behavior and spatial representations of patients with traumatic brain injury navigating in a real environment and in a virtual reproduction of this environment. Methods: Twenty-seven subjects with moderate to severe traumatic brain injury were consecutively included and allocated to one of two groups. The subjects were taught the same route in either the virtual environment or the real environment and had to recall it twice immediately after learning the route and once after a delay. At the end of these sessions, the subjects were asked to complete three representational tests: a map test, a map recognition test recognition and a scene arrangement test. Results: No significant difference was found between the two groups with regards to demographics, severity of brain injury or episodic memory. As a main result, the number of error rates did not significantly differ between the real and virtual environment [F (1, 25) = 0.679; p = 0.4176)]. Scores on the scene arrangement test were higher in the real environment [U = 32.5; p = 0.01]. Conclusions: Although spatial representations probably differ between the real and virtual environment, virtual reality remains a trusty assessment tool for spatial abilities. Implications for Rehabilitation The transfer of cognitive skills and strategy acquired during rehabilitation programs into daily life situations remains a matter of debate. Virtual reality might provide ecological and rehabilitation scenarios that can be used to look at the daily functioning of patients. The route learning performance after traumatic brain injury shows no significant difference between the real environment and its virtual reproduction in this study.

Safety and self-reported efficacy of botulinum toxin for adult spasticity in current clinical practice: a prospective observational study

Objective: To determine the safety and the self-reported efficacy of botulinum toxin injections for adult spasticity in current clinical practice. Design: A prospective observational study. Subjects: A total of 406 adult patients with focal spasticity received of 1136 series botulinum toxin injections at Bordeaux University Hospital from January 2007 to December 2009. Methods: Adverse events following botulinum toxin injections were reported. Their severity and the therapeutic efficacy of botulinum toxin injections were estimated with a four-point self-reporting scale (0 to 3). Latency and duration of adverse events and subjective improvement were also noted. Results: The data of 640 series of injections were analyzed. Forty-six (7.2%) adverse events were reported, of which 36 (78%) were local. There were 18 (39%) cases of local muscular weakness with an average duration of 30.0 (SD 38.2) days, and an average severity score of 1.0 (SD 0.97). Among systemic adverse events, there were 8 (17%) cases of excessive fatigue without global muscular weakness and 2 (4%) cases of transitory generalized muscular weakness. The average subjective improvement score was 1.89 (SD 0.97) and was higher for upper, than for lower, limbs (P=0.007). Conclusion: Self-reported adverse events following botulinum toxin injections in spasticity are rare, often benign and of short duration in current clinical practice. Botulinum toxin is considered effective by patients in treating spasticity of the upper and lower limbs.

Impact of contextual additional stimuli on the performance in a virtual activity of daily living (vADL) among patients with brain injury and controls

Abstract During recent years, researchers showed the feasibility and the interest of using virtual reality (VR)-based activities of daily living (vADL) among patients with cognitive impairments for the recovery of capacities. While interacting, the VR system provides various kinds of information for different purposes, including display of the virtual environment and understanding of the task, and also highlighting the functionalities or delivery of instructions. Generally, in order to improve the patient’s performance, additional cues are provided to enhance information saliency, such as arrows, change of colors, and so on. We give the definition of “contextual Additional Software Stimulus” (cASS) to any additional information related to the interaction and whose absence from the virtual environment does not have any effect on the unfolding of the task. This work was designed to study the effects of cASS on the performance in a daily living simulated task, including purchasing items in the Virtual Action Planning Supermarket (VAP-S). For this purpose, after implementation of cASS in the VAP-S, we carried out experiments, in which 23 healthy subjects (12 M and 11 F) and 12 patients with brain injury (12 M) took part. Results showed that the deliverance of cASS during the virtual task significantly improved some variables that described the performance of healthy subjects and patients with brain injury.

Effect of submental sensitive transcutaneous electrical stimulation on virtual lesions of the oropharyngeal cortex

OBJECTIVEnThe aim of this study was to assess the effect of submental sensitive transcutaneous electrical stimulation (SSTES) on pharyngeal cortical representation after the creation of an oropharyngeal cortical virtual lesion in healthy subjects.nnnMETHODSnMotor-evoked potential amplitude of the mylohyoid muscles was measured with transcranial magnetic stimulation (TMS), the oropharyngeal cortex was mapped by cartography, and videofluoroscopic parameters of swallowing function were measured before and after SSTES (at the end of SSTES [0 min] and at 30 and 60 min), after the creation of a cortical virtual lesion (repetitive TMS, 1 Hz, 20 min on the dominant swallowing hemisphere).nnnRESULTSnNine subjects completed the study. After 20 min of SSTES, motor-evoked potential amplitude increased (P<0.05), as did swallow reaction time after repetitive TMS, as seen on videofluoroscopy, which was reversed after electrical stimulation. On cortical mapping, the number of points with a cortical response increased in the dominant lesioned hemisphere (P<0.05), remaining constant at 60 min (P<0.05).nnnCONCLUSIONnSSTES may be effective for producing cortical plasticity for mylohyoid muscles and reverses oropharyngeal cortical inhibition in healthy subjects. It could be a simple non-invasive way to treat post-stroke dysphagia.

The effect of contextual auditory stimuli on virtual spatial navigation in patients with focal hemispheric lesions

ABSTRACT Topographical disorientation is a frequent deficit among patients suffering from brain injury. Spatial navigation can be explored in this population using virtual reality environments, even in the presence of motor or sensory disorders. Furthermore, the positive or negative impact of specific stimuli can be investigated. We studied how auditory stimuli influence the performance of brain-injured patients in a navigational task, using the Virtual Action Planning–Supermarket (VAP-S) with the addition of contextual (“sonar effect” and “name of product”) and non-contextual (“periodic randomised noises”) auditory stimuli. The study included 22 patients with a first unilateral hemispheric brain lesion and 17 healthy age-matched control subjects. After a software familiarisation, all subjects were tested without auditory stimuli, with a sonar effect or periodic random sounds in a random order, and with the stimulus “name of product”. Contextual auditory stimuli improved patient performance more than control group performance. Contextual stimuli benefited most patients with severe executive dysfunction or with severe unilateral neglect. These results indicate that contextual auditory stimuli are useful in the assessment of navigational abilities in brain-damaged patients and that they should be used in rehabilitation paradigms.

Improvement of Navigation and Representation in Virtual Reality after Prism Adaptation in Neglect Patients

Prism adaptation (PA) is responsible for an expansion of sensori-motor after-effects to cognitive domains for patients with spatial neglect. One important question is whether the cognitive after-effects induced by PA may also concern higher aspects of spatial cognition, such as navigation and topographic memory, which are critical in everyday life. The aim of this study was to assess whether multiple sessions of right PA can affect navigation and topographic memory. Seven right brain-damaged (RBD) patients with chronic neglect were included. We used a virtual supermarket named VAP-S which is an original paradigm, similar to the “shopping list test” during which patients had to purchase items from a list of eight products. Furthermore, in order to assess generalization of PA effects on constructing a spatial map from virtual information, each participant was then asked to draw the map of the virtual supermarket from memory. Regarding navigation performance, significant results were obtained: session duration reduction, fewer numbers of pauses and omissions, more items purchased on the left side and more items purchased over all. A long-lasting effect was noted, up to one month after PA. The representational task performance was also significantly increased for map drawing, with a reduction of the right shift of the symmetry axis of the map, more items drawn on the left side of maps and over all, and more items correctly located on the map. Some of these effects lasted for at least 7 days. These results suggest an expansion of PA benefit to a virtual environment. Crucially, the cognitive benefits induced by PA were noted for complex spatial cognition tasks required in everyday life such as navigation and topographic memory and this improvement was maintained for up to 1 month.

Virtual reality for cognitive rehabilitation: from new use of computers to better knowledge of brain black box?

Abstract Virtual reality (VR)-based technologies are one of the emerging tools that appear to have great potential for use in cognitive rehabilitation. However, it still is unclear how brain capacities are involved and what is the best approach to such training. Quantitative aspects are encouraging because some improvements have been shown after few training sessions. By contrast, qualitative design of VR tools is more questionable. Choice of errorless or error-full designs may depend on the severity of disturbances. Most VR tools emphasize the explicit component of tasks; even procedural aspects comprise the main strength of VR retraining programs. VR and augmented reality tools give various stimuli and indicators, but their best modalities stay unclear, given that most data are coming from learning studies in normal subjects more than rehabilitation studies in brain-injured patients. Specific studies to explore the impact of sensorial transmodal effects and emotional involvement in VR tasks are required. Rehabilitation protocols utilizing virtual environments are moving from single applications to cognitive impairment (i.e., alertness, memory, neglect, language, executive functions) to comprehensive rehabilitation programs, with the aim of achieving efficient improvement in autonomy and transfer of benefits in real life conditions. A core issue that presents challenges to rehabilitation is decreased ability of persons with brain injury to transfer learning from one situation or context to another. The multi-context approach to cognitive rehabilitation proposes treatment methods for teaching the use of strategies across a wide range of meaningful activities, which can promote generalization and enhance functional performance.

AGATHE: A tool for personalized rehabilitation of cognitive functions

Virtual Reality has recognized assets to address some cognitive rehabilitation issues. The purpose of this poster is to present an overview of the design of AGATHE, a tool for personalized rehabilitation of cognitive functions based on simulated Basic and Instrumental Activities of Daily Living (sBADL and sIADL).