[Disability after stroke: a longitudinal study in moderate and severe stroke patients included in a multidisciplinary rehabilitation program]

INTRODUCTION

Stroke is a recognized cause of disability among adults. However the impact that the deficits that occur after a moderate/severe stroke have on long-term disability, as well as the response of the resultant deficits to rehabilitation, are not completely understood.

PATIENTS AND METHODS

A total of 396 patients with a modified Rankin score >= 3 after an ischemic (n = 221) or hemorrhagic (n = 175) stroke were included in this study. All patients were assessed with cognitive, behavior, emotional, motor and functional domains. All patients were assessed at baseline and six months after inclusion in a multidisciplinary rehabilitation program.

RESULTS

Risk of falling (Berg Balance Scale < 45 in 83.1% of the sample at baseline and 49.5% at follow-up) and functional problems (82.8% with a Barthel Index < 75 at baseline and 53% at follow-up) were the most prevalent deficits. Emotional disturbances were those that most improved while behavioral problems were those that did less. Although global disability improved during treatment among most patients, only 11% of our patients, especially those with preserved cognitive function at baseline, could be classified as patients with mild disability at follow-up.

CONCLUSIONS

Stroke consequences are multidimensional. The symptoms that the stroke can cause in multiple domains, as well as the pattern of recovery are widely diverse, with prevalence of behavioral long-term disturbances.

[The clinical relevance of FDG-PET imaging in severe traumatic brain injuries]

AIM

To evaluate the usefulness of positron emission tomography (PET) as a predictor of long-term disability after a severe traumatic brain injury (TBI).

PATIENTS AND METHODS

Fifty-six patients who had sustained a severe TBI were assessed with a broad battery of cognitive and functional scales at baseline and 6-months after inclusion in a multidisciplinary rehabilitation program. All patients underwent a FDG-PET at baseline. A physician blind to clinical data performed a semiquantitative analysis (normal vs altered) of functional neuroimaging (PET), including four cortical and three subcortical areas. The total number of lesions (cortical, subcortical and total) was correlated to the intensity of the TBI and to clinical data at admission and at follow-up.

RESULTS

All patients showed changes in cerebral metabolism, being the thalamus the area most frequently affected. The degree of cerebral hypometabolism showed a significant correlation with TBI severity, functional disability, global outcome and cognitive impairment not only at baseline but also at follow-up.

CONCLUSIONS

According to our results, FDG-PET may be a useful tool when studying brain dysfunction after severe TBI. FDG-PET findings correlate with the TBI severity, and with the level of patients' disability, as well as with the degree of memory and intelligence impairment. However, clinical variables related to the severity of the TBI, still are the best predictors of functional outcome after TBI.

[Clinical utility of the 64-card version of the Wisconsin Card Sorting Test in patients with traumatic brain injury]

AIMS

To analyze the validity of the single deck 64-card Wisconsin Card Sorting Test (WCST-64) compared to the standard version (WCST-128), and to study the sensibility of both versions to identify changes over time in patients with traumatic brain injury (TBI).

PATIENTS AND METHODS

The WCST was administered twice across a 6-month period to a sample of 50 patients with TBI. Pearson correlation coefficients were calculated to examine bivariate associations between WCST-128 scores and the corresponding WCST-64 scores at inclusion and at follow-up. Agreement in classification of impairment (z = -1) or normal performance was calculated for the two tests (kappa). Significant change over time was also analyzed for both versions of the test (paired-samples t test).

RESULTS

The results revealed positive and significant correlations between both measures as well as a significant agreement in the classification of patients as having deficits or not. Moreover, the WCST-128 and the WCST-64 showed similar ability to identify changes over time.

CONCLUSIONS

Our findings showed strong associations between scores derived from the two test and support the comparability of both versions when analyzing cross-sectional or longitudinal data. The findings support the use of the WCST-64 in evaluations of executive deficits of patients with moderate and severe TBI.

[When do patients with traumatic brain injury lose verbal information? Implications for cognitive rehabilitation]

AIM

Longitudinal study of verbal learning and memory processes after traumatic brain injury (TBI).

PATIENTS AND METHODS

Twenty-six patients who had sustained a moderate-severe TBI were assessed with a Spanish version of the California Verbal Learning Test at the time of admission and 6-months after inclusion in a multidisciplinary rehabilitation program that comprised rehabilitation strategies for memory impairments. Global memory indexes were determined, including retroactive interference, proactive interference and recall indexes controlled for level of verbal acquisition. Memory change over time was correlated to demographic and clinical relevant variables, including the level of patients' self-awareness.

RESULTS

More than 75% of our patients presented learning, immediate memory and delayed memory deficits at baseline, with an important effect of retroactive interference (69%). At 6-month follow-up, 34.6% showed learning difficulties, 46.2% immediate memory deficits, and 53% delayed memory problems, with 34.6% of the patients showing retroactive interference. Chronicity, level of self-awareness and premorbid intelligence correlated to the degree of memory change over time.

CONCLUSIONS

Prominent verbal memory problems developed, not only during the first months after TBI but also over time are mostly due to impaired consolidation related to an intense retroactive interference. These data should be considered when developing memory rehabilitation strategies.

[The 'awareness climbing': an educational board game for improving self-awareness following acquired brain injury]

AIM

To establish the effectiveness of an educational board game for improving self-awareness following acquired brain injury.

PATIENTS AND METHODS

The 'awareness climbing' is a board game format intervention for improving awareness of patients with acquired brain injury (ABI) and for facilitating the use of anticipatory and compensatory strategies. 17 patients with ABI (traumatic brain injury, 10; stroke, 5; others, 2) were included in a self-awareness rehabilitation program using the 'awareness climbing'. Self-awareness was assessed with the Self-Awareness of Deficit Interview (SADI) before and after game intervention. According to the SADI self-awareness consists of three-interdependent levels: intellectual awareness (impairments), emergent awareness (disability) and anticipatory awareness, which involve the client predicting when impairments will affect his or her performance.

RESULTS

Initially five patients showed impaired intellectual awareness, four patients had difficulties on emergent awareness and nine patients showed deficits on anticipatory awareness. Intellectual awareness improved in 10 patients, while six patients experienced improvements in emergent awareness over the intervention period. The most striking change was an improvement in 70% of the sample (n = 11) in anticipatory awareness after game sessions.

CONCLUSION

According to SADI scores we suggest that the 'awareness climbing' may be a useful tool for improving self-awareness after acquired brain injury.

[Anoxic encephalopathy. Clinical description, prognosis and neuroimaging]

OBJECTIVES

To describe the clinical profile (neuropsychological, psychopathological, functional and neuroimaging), as well as the evolution of patients with anoxic encephalopathy.

PATIENTS AND METHODS

Nine patients with anoxic encephalopathy attending our Service were included in the study. All patients were assessed with a broad range of neuropsychological tests, checklists of psychopathological symptoms, and several functional scales. A CT/MRI or a positron emission tomography (PET) were performed in five patients. Five patients were admitted to a multidisciplinary rehabilitation program.

RESULTS

All patients showed problems in orientation, executive functions, verbal learning an immediate and long-term verbal memory, in association with diffuse cognitive changes in other functions. Psychopathologically, all patients showed apathy-indifference, and eight subjects showed anosognosia. All subjects have an important dependence in daily activities. CT/MRI were normal or showed subcortical changes whereas the PET showed a predominantly cortical hypometabolism with specific patterns. There were no significant improvements after rehabilitation in treated patients.

CONCLUSION

In the absence of a unique clinical profile, our patients with anoxic encephalopathy showed similarities in their symptoms (diffuse cognitive deficits with predominance of amnesic and executive impairments; presence of apathy and anosognosia; complete functional dependence; and poor response to the rehabilitation). Functional neuroimaging could be a useful tool for a better understanding of these encephalopathies.

[Intelligence, memory and malingering: correlation between scales]

OBJECTIVES

To validate the test of memory malingering (TOMM), and to study the influence of intelligence and memory on its performance in brain injury patients.

PATIENTS AND METHODS

A total of 30 patients with traumatic head injury were included in the study. All patients were assessed with the Complutense verbal learning test, the Visual Reproduction subtest of the Wechsler memory scale-revised, the Boston naming test, two fluency tests (FAS, and animals), the Wechsler adult intelligence test-III, and with the TOMM. Cognitive results below 1 standard deviation (SD) from normative data were considered 'abnormal'. A parametric correlation between TOMM scores and cognitive tests was used to detect whether memory and intelligence were affecting TOMM performance. Statistical significance was set up at p<0.05.

RESULTS

Between 46.1% (Boston) and 81.4% (WAIS-III performance IQ) of the sample presented cognitive deficits. Up to 83.3% of the patients scored above the cutoff point suggestive of malingering in the TOMM (45/50). Significance correlations were found between TOMM scores and memory or intelligence indexes.

DISCUSSION

The TOMM is a useful tool to detect malingering in head injured patients. Effects of low intelligence coefficients, as well as memory deficits should be considered in clinical practice when evaluating patients with TOMM scores suggestive of malingering.