Walter Daveluy

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 TBIs 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.

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.

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. Cronbachs 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.

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.

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.

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 patients 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 patients perception (in a questionnaire) and the examiners perception (in a practical test) of upright standing and walking impairments and their impact on activities of daily living. We analyzed the LL-FASs reliability, construct validity, internal consistency, predictive validity and feasibility. RESULTS Thirty-five stroke patients were included. The scales 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.

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

ABSTRACT 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.

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.

Validation d’une échelle d’évaluation analytique et fonctionnelle de l’équilibre et de la marche chez le patient hémiplégique vasculaire

presentant une aphasie totale (score ASRS de Goodglass et Kaplan a 0) n’a pu passer l’entretien. Celui-ci a ete difficile chez 3 patients (deux ASRS 1, un ASRS 2), possible avec reformulations chez 16, et facile chez les 12 autres. Il existe des differences significatives avec les scores des temoins dans 5 des 6 categories CIF notamment pour les itemsRP entretien du linge, deplacements exterieurs, courses et achats, budget, relations avec des inconnus, loisirs de groupe, vie associative et demarches administratives. Parmi les facteurs d’environnement, le soutien social est juge satisfaisant dans 79,5%des situations. Les attitudes des autres sont jugees 3 a 4 fois plus souvent facilitatricesqu’obstacles. Le facteurSystemeset politiques est facilitateur pour Soins personnels, Vie domestique, Vie communautaire, mais plutot obstacle pour Relations et Loisirs. Discussion.– La GMAP est applicable a la plupart des personnes aphasiques, mais des versions multi-sources seront utiles chez ces patients. Le modele CIF parait pertinent pour comprendre leurs difficultes de participation. Reference [1] Belio C, Prouteau A, Koleck M, Saada Y, Merceron K, Destaillats JM, et al. Participation in patients with psychic and/or cognitive impairments. Annals PRM 2013 [in print]..

Validation of the posture and gait – Impairments and activities for stroke patients (PG-IASP) scale

In particular, the content validity (the scale measures well the desired concept, with a good understanding of the issues by the patients), the construct validity (dimensionality of the scale), the criterion validity (good correlations with other variables), and the reliability of scores (precision of the score, reproducibility) are studied. The CTT is an important step in the validation of scales and allows building correct scores for use in medical practice. In clinical research and in epidemiology, however, other qualities of scores can be sought in particular it could be interesting to obtain an interval measure (i.e., a measure which any difference is similarly interpreted at any level of the score: this property justifies the use of averages in groups of patients), and to obtain a measure independent of the items answered by patients (for an efficient handling of missing data, undeniable source of bias when patients respond only partially to the questionnaires). The Item Response Theory (IRT) [1] is a set of models to obtain an interval measure of a subjective concept. In addition, in this theory, the Rasch model [1] provides a measure independent of answered items. The objective of this presentation is to present the IRT and particularly the Rasch model for validation of scale, and show its application in clinical practice on the basis of a scale-specific quality of life in patients with neuromuscular diseases (the QolNMD) validated through this model. Reference [1] Andrich A. Rating scale and Rasch measurement. Expert Rev Pharmacoeconomics Outcomes Res 2011;11(5):571–85.