Predictors of quality of life after moderate to severe traumatic brain injury.

Objective To verify correlations between age, injury severity, length of stay (LOS), cognition, functional capacity and quality of life (QOL) six months after hospital discharge (HD) of victims of traumatic brain injury (TBI). Method 50 patients consecutively treated in a Brazilian emergency hospital were assessed at admission, HD and six months after HD. The assessment protocol consisted in Abbreviated Injury Scale, Injury Severity Score, Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), Mini Mental Test, Barthel Index and World Health Organization QOL - Brief. Results Strong negative correlation was observed between LOS and GCS and LOS and RTS. An almost maximal correlation was found between RTS and GCS and functional capacity and GCS at HD. Age and LOS were considered independent predictors of QOL. Conclusion Age and LOS are independent predictors of QOL after moderate to severe TBI.

Predictors of quality of life after moderate to severe traumatic brain injury / Preditores de qualidade de vida após trauma crânio-encefálico moderado a grave

ABSTRACT Objective To verify correlations between age, injury severity, length of stay (LOS), cognition, functional capacity and quality of life (QOL) six months after hospital discharge (HD) of victims of traumatic brain injury (TBI). Method 50 patients consecutively treated in a Brazilian emergency hospital were assessed at admission, HD and six months after HD. The assessment protocol consisted in Abbreviated Injury Scale, Injury Severity Score, Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), Mini Mental Test, Barthel Index and World Health Organization QOL - Brief. Results Strong negative correlation was observed between LOS and GCS and LOS and RTS. An almost maximal correlation was found between RTS and GCS and functional capacity and GCS at HD. Age and LOS were considered independent predictors of QOL. Conclusion Age and LOS are independent predictors of QOL after moderate to severe TBI.

RESUMO Objetivo Verificar correlações entre idade, gravidade do trauma, tempo de hospitalização (TH), cognição, capacidade funcional e qualidade de vida (QV) seis meses após alta hospitalar (AH) de vítimas de trauma crânio-encefálico (TCE). Método 50 pacientes tratados em um hospital de emergência brasileiro foram avaliados na admissão, AH e seis meses após AH. O protocolo de avaliação consistia em Escala Abreviada de Lesões, Índice de Gravidade de Lesão, Escala de Coma de Glasgow (ECG), Escore de Trauma Revisado (RTS), teste Mini-Mental, Índice de Barthel e Questionário Breve de QV da Organização Mundial de Saúde. Resultados Forte correlação negativa foi observada entre TH e ECG e TH e RTS. Correlação quase máxima foi observada entre RTS e ECG e capacidade funcional e ECG na AH. Idade e TH foram considerados preditores independentes de QV. Conclusão Idade e TH são preditores independentes de QV após TCE moderado e grave.

Polarity-Dependent Misperception of Subjective Visual Vertical during and after Transcranial Direct Current Stimulation (tDCS).

Pathologic tilt of subjective visual vertical (SVV) frequently has adverse functional consequences for patients with stroke and vestibular disorders. Repetitive transcranial magnetic stimulation (rTMS) of the supramarginal gyrus can produce a transitory tilt on SVV in healthy subjects. However, the effect of transcranial direct current stimulation (tDCS) on SVV has never been systematically studied. We investigated whether bilateral tDCS over the temporal-parietal region could result in both online and offline SVV misperception in healthy subjects. In a randomized, sham-controlled, single-blind crossover pilot study, thirteen healthy subjects performed tests of SVV before, during and after the tDCS applied over the temporal-parietal region in three conditions used on different days: right anode/left cathode; right cathode/left anode; and sham. Subjects were blind to the tDCS conditions. Montage-specific current flow patterns were investigated using computational models. SVV was significantly displaced towards the anode during both active stimulation conditions when compared to sham condition. Immediately after both active conditions, there were rebound effects. Longer lasting after-effects towards the anode occurred only in the right cathode/left anode condition. Current flow models predicted the stimulation of temporal-parietal regions under the electrodes and deep clusters in the posterior limb of the internal capsule. The present findings indicate that tDCS over the temporal-parietal region can significantly alter human SVV perception. This tDCS approach may be a potential clinical tool for the treatment of SVV misperception in neurological patients.

Verticality Perceptions Associate with Postural Control and Functionality in Stroke Patients.

Deficits of postural control and perceptions of verticality are disabling problems observed in stroke patients that have been recently correlated to each other. However, there is no evidence in the literature confirming this relationship with quantitative posturography analysis. Therefore, the objectives of the present study were to analyze the relationship between Subjective Postural Vertical (SPV) and Haptic Vertical (HV) with posturography and functionality in stroke patients. We included 45 stroke patients. The study protocol was composed by clinical interview, evaluation of SPV and HV in roll and pitch planes and posturography. Posturography was measured in the sitting and standing positions under the conditions: eyes open, stable surface (EOSS); eyes closed, stable surface (ECSS); eyes open, unstable surface (EOUS); and eyes closed, unstable surface (ECUS). The median PV in roll plane was 0.34° (-1.44° to 2.54°) and in pitch plane 0.36° (-2.72° to 2.45°). The median of HV in roll and pitch planes were -0.94° (-5.86° to 3.84°) and 3.56° (-0.68° to 8.36°), respectively. SPV in the roll plane was correlated with all posturagraphy parameters in sitting position in all conditions (r = 0.35 to 0.47; p < 0.006). There were moderate correlations with the verticality perceptions and all the functional scales. Linear regression model showed association between speed and SPV in the roll plane in the condition EOSS (R2 of 0.37; p = 0.005), in the condition ECSS (R2 of 0.13; p = 0.04) and in the condition EOUS (R2 of 0.22; p = 0.03). These results suggest that verticality perception is a relevant component of postural control and should be systematically evaluated, particularly in patients with abnormal postural control.

Subjective Visual Vertical during Caloric Stimulation in Healthy Subjects: Implications to Research and Neurorehabilitation.

Background. The subjective visual vertical (SVV) is a perception often impaired in patients with neurologic disorders and is considered a sensitive tool to detect otolithic dysfunctions. However, it remains unclear whether the semicircular canals (SCCs) are also involved in the visual vertical perception. Objective. The aim of this study was to analyze the influence of horizontal SCCs on SVV by caloric stimulation in healthy subjects. Methods. SVV was performed before and during the ice-cold caloric stimulation (4°C, right ear) in 30 healthy subjects. Results. The mean SVV tilts before and during the caloric stimulation were 0.31° ± 0.39 and -0.28° ± 0.40, respectively. There was no significant difference between the mean SVV tilts before and during stimulation (p = 0.113). Conclusion. These results suggest that horizontal SCCs do not influence SVV. Therefore, investigations and rehabilitation approaches for SVV misperceptions should be focused on otolithic and cognitive strategies.

Validation of a structured interview for telephone assessment of the modified Rankin Scale in Brazilian stroke patients.

BACKGROUND: The modified Rankin Scale (mRS) is a commonly used scale to assess the functional outcome after stroke. Several studies on mRS showed good reliability, feasibility, and interrater agreement of this scale using a face-to-face assessment. However, telephone assessment is a more time-efficient way to obtain an mRS grade than a face-to-face interview. The aim of this study was to validate the telephone assessment of mRS among the Portuguese using a structured interview in a sample of Brazilian stroke patients. METHODS: We evaluated 50 stroke outpatients twice. The first interview was face-to-face and the second was made by telephone and the time between the two assessments ranged between 7 and 14 days. Four certified raters evaluated the patients using a structured interview based on a questionnaire previously published in the literature. Raters were blinded for the Rankin score given by the other rater. For both assessments, the rater could also interview a caregiver if necessary. RESULTS: The patients' mean age was 62.8 ± 14.7, mean number of years of study 5.2 ± 3.4, 52% were males, 55.2% of patients needed a caregiver's help to answer the questions. The majority of caregivers were female (85%), mean age 49.1 ± 15, and mean number of years of study 8.3 ± 3.4. Perfect agreement between the telephone and face-to-face assessments was obtained for 27 (54%) patients, corresponding to an unweighted Kappa of 0.44 (95% CI 0.27-0.61) and a weighted Kappa of 0.89. The median of telephone assessment mRS was 3.5 (interquartile range = 2-4) and of face-to-face assessment was 4 (interquartile range = 2-5). There was no difference between the two assessments (Wilcoxon test, p = 0.35). CONCLUSIONS: Despite the low education level of our sample, the telephone assessment of functional impairment of stroke patients using a translated and culturally adapted Brazilian Portuguese version of the mRS showed good validity and reliability. Therefore, the telephone assessment of mRS can be used in clinical practice and scientific studies in Brazil.

SOS score: an optimized score to screen acute stroke patients for obstructive sleep apnea.

BACKGROUND: Obstructive sleep apnea (OSA) is frequent in acute stroke patients, and has been associated with higher mortality and worse prognosis. Polysomnography (PSG) is the gold standard diagnostic method for OSA, but it is impracticable as a routine for all acute stroke patients. We evaluated the accuracy of two OSA screening tools, the Berlin Questionnaire (BQ), and the Epworth Sleepiness Scale (ESS) when administered to relatives of acute stroke patients; we also compared these tools against a combined screening score (SOS score). METHODS: Ischemic stroke patients were submitted to a full PSG at the first night after onset of symptoms. OSA severity was measured by apnea-hypopnea index (AHI). BQ and ESS were administered to relatives of stroke patients before the PSG and compared to SOS score for accuracy and C-statistics. RESULTS: We prospectively studied 39 patients. OSA (AHI ≥10/h) was present in 76.9%. The SOS score [area under the curve (AUC): 0.812; P = 0.005] and ESS (AUC: 0.789; P = 0.009) had good predictive value for OSA. The SOS score was the only tool with significant predictive value (AUC: 0.686; P = 0.048) for severe OSA (AHI ≥30/h), when compared to ESS (P = 0.119) and BQ (P = 0.191). The threshold of SOS ≤10 showed high sensitivity (90%) and negative predictive value (96.2%) for OSA; SOS ≥20 showed high specificity (100%) and positive predictive value (92.5%) for severe OSA. CONCLUSIONS: The SOS score administered to relatives of stroke patients is a useful tool to screen for OSA and may decrease the need for PSG in acute stroke setting.

Obese elderly women exhibit low postural stability: a novel three-dimensional evaluation system.

OBJECTIVE: The aim of this study was to evaluate the multisegmental static postural balance of active eutrophic and obese elderly women using a three-dimensional system under different sensory conditions. METHODS: A cross-sectional study was conducted on 31 elderly women (16 eutrophic and 15 obese) aged 65 to 75 years. The following anthropometric measurements were obtained: weight, height, waist and hip circumference, and handgrip strength. The physical activity level was evaluated using the International Physical Activity Questionnaire. Body composition was measured using the deuterium oxide dilution technique. The Polhemus(®) Patriot (three-dimensional) equipment was used to measure the parameters of postural balance along the anteroposterior and laterolateral axes. The data acquisition involved one trial of 60 s to test the limit of stability and four trials of 90 s each under the following conditions: (1) eyes open, stable surface; (2) eyes closed, stable surface; (3) eyes open, unstable surface; and (4) eyes closed, unstable surface. RESULTS: For the limit of stability, significant differences were observed in the maximum anteroposterior and laterolateral displacement (p<0.01) and in the parameter maximum anteroposterior displacement in the eyes closed stable surface condition (p<0.01) and maximum anteroposterior and laterolateral displacement in the eyes open unstable surface (p<0.01 and p = 0.03) and eyes closed unstable surface (p<0.01 and p<0.01) conditions. CONCLUSIONS: Obese elderly women exhibited a lower stability limit (lower sway area) compared with eutrophic women, leaving them more vulnerable to falls.

Obese elderly women exhibit low postural stability: a novel three-dimensional evaluation system

OBJECTIVE: The aim of this study was to evaluate the multisegmental static postural balance of active eutrophic and obese elderly women using a three-dimensional system under different sensory conditions. METHODS: A cross-sectional study was conducted on 31 elderly women (16 eutrophic and 15 obese) aged 65 to 75 years. The following anthropometric measurements were obtained: weight, height, waist and hip circumference, and handgrip strength. The physical activity level was evaluated using the International Physical Activity Questionnaire. Body composition was measured using the deuterium oxide dilution technique. The Polhemus® Patriot (three-dimensional) equipment was used to measure the parameters of postural balance along the anteroposterior and laterolateral axes. The data acquisition involved one trial of 60 s to test the limit of stability and four trials of 90 s each under the following conditions: (1) eyes open, stable surface; (2) eyes closed, stable surface; (3) eyes open, unstable surface; and (4) eyes closed, unstable surface. RESULTS: For the limit of stability, significant differences were observed in the maximum anteroposterior and laterolateral displacement (p<0.01) and in the parameter maximum anteroposterior displacement in the eyes closed stable surface condition (p<0.01) and maximum anteroposterior and laterolateral displacement in the eyes open unstable surface (p<0.01 and p = 0.03) and eyes closed unstable surface (p<0.01 and p<0.01) conditions. CONCLUSIONS: Obese elderly women exhibited a lower stability limit (lower sway area) compared with eutrophic women, leaving them more vulnerable to falls.

The use of a neck brace does not influence visual vertical perception.

UNLABELLED: Subjective visual vertical (SVV) evaluates the individual's capacity to determine the vertical orientation. Using a neck brace (NB) allow volunteers' heads fixation to reduce cephalic tilt during the exam, preventing compensatory ocular torsion and erroneous influence on SVV result. OBJECTIVE: To analyze the influence of somatosensory inputs caused by a NB on the SVV. METHOD: Thirty healthy volunteers performed static and dynamic SVV: six measures with and six without the NB. RESULTS: The mean values for static SVV were -0.075º±1.15º without NB and -0.372º±1.21º with NB. For dynamic SVV in clockwise direction were 1.73º±2.31º without NB and 1.53º±1.80º with NB. For dynamic SVV in counterclockwise direction was -1.50º±2.44º without NB and -1.11º±2.46º with NB. Differences between measurements with and without the NB were not statistically significant. CONCLUSION: Although the neck has many sensory receptors, the use of a NB does not provide sufficient afferent input to change healthy subjects' perception of visual verticality.

The use of a neck brace does not influence visual vertical perception / O uso do colar cervical não influência na percepção de verticalidade visual

Subjective visual vertical (SVV) evaluates the individual's capacity to determine the vertical orientation. Using a neck brace (NB) allow volunteers' heads fixation to reduce cephalic tilt during the exam, preventing compensatory ocular torsion and erroneous influence on SVV result. OBJECTIVE: To analyze the influence of somatosensory inputs caused by a NB on the SVV. METHOD: Thirty healthy volunteers performed static and dynamic SVV: six measures with and six without the NB. RESULTS: The mean values for static SVV were -0.075º±1.15º without NB and -0.372º±1.21º with NB. For dynamic SVV in clockwise direction were 1.73º±2.31º without NB and 1.53º±1.80º with NB. For dynamic SVV in counterclockwise direction was -1.50º±2.44º without NB and -1.11º±2.46º with NB. Differences between measurements with and without the NB were not statistically significant. CONCLUSION: Although the neck has many sensory receptors, the use of a NB does not provide sufficient afferent input to change healthy subjects' perception of visual verticality.

A subjetiva vertical visual (SVV) avalia a capacidade do indivíduo determinar a posição vertical. O uso do colar cervical (CC) fixa a cabeça do voluntário, reduzindo a inclicação cefálica durante o exame e prevenindo a torção ocular compensatória que influencia na SVV. OBJETIVO: Analisar a influência de informações sometossensoriais causadas pelo uso de um CC na SVV. MÉTODO: Trinta voluntários saudáveis realizaram a SVV estática e dinâmica: seis medidas com e seis medidas sem o CC. RESULTADOS: O valor médio da SVV estática foi -0,075º±1,15º sem CC e -0,372º±1,21º com. Na SVV dinâmica no sentido horário foi 1,73º±2,31º sem CC e 1,53º±1,80º com. Na SVV dinâmica no sentido anti-horário foi -1,50º±2,44º sem CC e -1,11º±2,46º com. As diferenças entre as medidas com e sem CC não foram estatisticamente significativas. CONCLUSÃO: Apesar de o pescoço possuir inumeros receptores sensoriais, o uso do CC não fornece aferências suficientes para alterar a percepção de visual de verticalidade de voluntários saudáveis.

Comparação da oscilação postural estática na posição sentada entre jovens e idosos saudáveis / Comparing static sitting postural sway of healthy young and older adults

OBJETIVOS: Descrever uma nova metodologia de análise da oscilação postural estática sentada e comparar os resultados de jovens e idosos saudáveis. MÉTODOS: Participaram do estudo 38 indivíduos saudáveis, 17 jovens (idade média 23±2,38 anos) e 21 idosos (idade média 67±2,42 anos). A oscilação postural foi mensurada por meio do sistema eletromagnético Polhemus® 3Space Isotrack II. As avaliações foram feitas nas condições olhos abertos (OA) e fechados (OF), com os voluntários sentados sem apoio plantar e sem encosto em suportes de madeira (superfície estável-SE) e de espuma (superfície instável-SI). Cada condição sensorial foi avaliada durante 90 segundos. Os parâmetros analisados foram: deslocamento máximo (Dmáx), trajetória total (Traj) e velocidade média (Vel) nos planos sagital (X) e frontal (Y). RESULTADOS: Nas condições OA e OF em SE, foram encontradas oscilações nos planos X e Y dos parâmetros Traj e Vel maiores em jovens que em idosos. Em SI, foram observadas maiores Traj Y e Vel Y nos jovens, sem diferença significativa entre os grupos quanto a Traj X e Vel X com olhos fechados. Em relação ao Dmáx, tanto no plano X quanto no Y, em todas as condições sensoriais, só houve diferença significativa na condição OASE no plano sagital, sendo maior nos jovens. CONCLUSÕES: Jovens saudáveis oscilam mais que os idosos saudáveis na posição sentada. Além disso, a ferramenta utilizada mostrou ser útil para análise da oscilação postural estática na posição sentada, possibilitando o surgimento de estudos que a associem com o efeito de diversas tarefas motoras.

OBJECTIVES: To describe a new method to analyze the static sitting postural sway and to compare the results of healthy young and older adult subjects. METHODS: Thirty-eight healthy subjects took part in the study, including 17 young adults (mean age 23±2.38 years old) and 21 older adults (mean age 67±2.42 years old). The device used to quantify trunk sway was the magnetic field sensor Polhemus® 3Space Isotrack II. The measurements were taken in the eyes-opened (EO) and eyes-closed (EC) condition with the subjects seated first on a wooden stable surface (SS) then on a foam unstable surface (US) without back or foot support. Each sensory condition was assessed for 90 seconds. The analyzed parameters were: maximum amplitude (Amp), total trajectory (Traj) and mean velocity (Vel) in the sagittal (X) and frontal (Y) planes. RESULTS: In the EO and EC conditions on SS, young adults presented greater postural sway in the X and Y planes on the Traj and Vel parameters. In the US, young adults showed greater Y Traj and Y Vel in the EO and EC conditions, and there was no significant difference between the groups with regard to X Traj and X Vel in the EC condition. The young adults presented greater Amp only in the EOSS condition in the X plane. CONCLUSIONS: The young adult subjects presented greater sway in the sitting position than the older adult subjects. In addition, the Polhemus® device was a useful tool to analyze static sitting postural sway and can be used in future studies that associate static sitting postural sway with the effect of various motor tasks.

Human variability of fMRI brain activation in response to oculomotor stimuli.

Assessing interindividual variability of brain activation is of practical importance to the use of functional magnetic resonance imaging (fMRI) in the clinical context. The main objective of this study is to analyze the variability of the oculomotor system through horizontal optokinetic, pursuit and saccadic eye movement stimulations by means of fMRI. We found significant activation of many cortical and subcortical structures. The frequency of activation demonstrates a high variability between subjects. However, the most frequent activation regions were located in frontal areas and in regions comprising the middle temporal and medial superior temporal areas. Our study allowed the characterization of the most frequently involved foci in optokinetic stimulation, pursuit and saccadic eye movement tasks. The combination of these tasks constitutes a suitable tool for mapping major areas involved in the oculomotor system.

Pushing behavior and hemiparesis: which is critical for functional recovery in pusher patients ? Case report.

We report a sequential neuroimaging study in a 48-years-old man with a history of chronic hypertension and lacunar strokes involving the ventral lateral posterior nucleus of the thalamus. The patient developed mild hemiparesis and severe contraversive pushing behavior after an acute hemorrhage affecting the right thalamus. Following standard motor physiotherapy, the pusher behavior completely resolved 3 months after the onset and, at that time, he had a Barthel Index of 85, although mild left hemiparesis was still present. This case report illustrates that pushing behavior itself may be severely incapacitating, may occur with only mild hemiparesis and affected patients may have dramatic functional improvement (Barthel Index 0 to 85) after resolution pushing behavior without recovery of hemiparesis.

Pushing behavior and hemiparesis: which is critical for functional recovery in pusher patients?: case report

We report a sequential neuroimaging study in a 48-years-old man with a history of chronic hypertension and lacunar strokes involving the ventral lateral posterior nucleus of the thalamus. The patient developed mild hemiparesis and severe contraversive pushing behavior after an acute hemorrhage affecting the right thalamus. Following standard motor physiotherapy, the pusher behavior completely resolved 3 months after the onset and, at that time, he had a Barthel Index of 85, although mild left hemiparesis was still present. This case report illustrates that pushing behavior itself may be severely incapacitating, may occur with only mild hemiparesis and affected patients may have dramatic functional improvement (Barthel Index 0 to 85) after resolution pushing behavior without recovery of hemiparesis.

Relatamos o estudo de neuroimagem seqüencial de um homem de 48 anos com história de hipertensão arterial crônica e acidentes vasculares cerebrais (AVCs) lacunares nos núcleos ventral lateral posterior do tálamo. O paciente desenvolveu hemiparesia leve e síndrome do empurrador (SE) grave após AVC hemorrágico no tálamo direito, sendo tratado com fisioterapia motora convencional. Três meses após o ictus, os sinais da síndrome haviam desaparecido e o paciente apresentava índice de Barthel 85, apesar da permanência da hemiparesia leve. Este caso demonstra que a síndrome do empurrador isolada pode ser gravemente incapacitante, pode ocorrer associada a hemiparesia leve e que os pacientes com esta síndrome podem apresentar recuperação funcional importante (índice de Barthel inicial 0 e final 85) após a resolução da SP sem alteração do grau de hemiparesia.

Contraversive pushing in non-stroke patients.

BACKGROUND: Pusher syndrome is a disorder of postural control observed in patients with right or left brain damage associated with hemiparesis. Those patients show a peculiar behavior of actively pushing away from the nonhemiparetic side and resisting against passive correction, with a tendency to fall toward the paralyzed side. Thus far this phenomenon has been exclusively associated with stroke patients. OBJECTIVE: We investigate the occurrence, imaging features and clinical evolution of pusher behavior in patients with acute encephalic lesions at a tertiary emergency hospital. METHODS: Pusher patients were identified from 530 inpatients during a 1 year period. Patients were evaluated using a standardized Scale for Contraversive Pushing (SCP), neurological examination, assessment of neuropsychological symptoms, activities of daily living function and neuroimaging studies. RESULTS: We found eight patients (1.5%) with severe contraversive pushing, three female and five male. Age at symptoms onset ranged from 48 to 80 years (mean 65.4). All patients had scores equal or above 1.5 in each tested parameter of the SCP. Six patients (75 %) had right-hemisphere brain damage. A stroke etiology was found in four patients. The other four patients had non-stroke etiology (three traumatic, one metastatic tumor). Stroke patients showed complete recovery of pusher behavior at a mean duration of 15.3 weeks. In patients with brain trauma, pushing behavior was completely resolved in a mean time of 5 weeks. CONCLUSIONS: The results demonstrate that contraversive pushing may also occur in patients with non-stroke neurological lesions and suggest that resolution of symptoms may vary according to the underlying etiology.