Brain-actuated functional electrical stimulation elicits lasting arm motor recovery after stroke.

Brain-computer interfaces (BCI) are used in stroke rehabilitation to translate brain signals into intended movements of the paralyzed limb. However, the efficacy and mechanisms of BCI-based therapies remain unclear. Here we show that BCI coupled to functional electrical stimulation (FES) elicits significant, clinically relevant, and lasting motor recovery in chronic stroke survivors more effectively than sham FES. Such recovery is associated to quantitative signatures of functional neuroplasticity. BCI patients exhibit a significant functional recovery after the intervention, which remains 6-12 months after the end of therapy. Electroencephalography analysis pinpoints significant differences in favor of the BCI group, mainly consisting in an increase in functional connectivity between motor areas in the affected hemisphere. This increase is significantly correlated with functional improvement. Results illustrate how a BCI-FES therapy can drive significant functional recovery and purposeful plasticity thanks to contingent activation of body natural efferent and afferent pathways.

Influence of intrathecal baclofen on the level of consciousness and mental functions after extremely severe traumatic brain injury: brief report.

BACKGROUND: Whenever oral treatment or botulinum toxin injections fail to control severe spasticity, a trial with intrathecal baclofen is recommended no earlier than 1 year after brain injury. When irreversible contractures are to be avoided, such a trial might be done earlier. Some have briefly reported cognitive modifications with this treatment. METHODS: During the trial period, intrathecal baclofen is continuously infused by a portable external pump through an intrathecal catheter. The daily dose is adjusted according to the clinical response. If the expected response is obtained by reduction of spasticity, a programmable pump is then implanted. Throughout the procedure, close neuropsychological follow-up is pursued. RESULTS: Two persons with extremely severe brain injury and spasticity received a programmable pump less than 10 months after trauma. Unexpectedly, one emerged from the minimally conscious state and the other from post-traumatic amnesia. CONCLUSIONS: Intrathecal baclofen should be considered within the first year after brain injury whenever spasticity does not respond to medication. ITB lessens the degree of spasticity which in turn facilitates care and, thus, has the potential to limit contractures. After severe brain injury, this treatment might trigger recovery from altered states of consciousness, improve cognition and facilitate rehabilitation.

[Interest and costs of neurorehabilitation of brain injury patients]. / Intérêt et coût de la réadaptation neurologique des patients cérébrolésés.

The severity of the initial deficit and the improvement in the first weeks are the strongest indicators for a favorable outcome after stroke. Meta-analyses attempt to evaluate the efficacy of neurorehabilitation, but the results are unconclusive due to the heterogeinity of the groups of patients and therapies. However, there is sufficient data to conclude that repetitive, high intensity, task orientated training is efficacious. New approaches (mental imagery, robotics, virtual therapies...) are also useful but are not better than physiotherapy. It is as important to individualize the approach in a multidisciplinary well organised and communicative setting and to treat early complications. Cerebral plasticity is an individualized process and limited in time, so therapy should be regularly adapted and stopped if the deficit remains stable.

[Relevance of a driving simulator in the assessment of handicapped individuals]. / Intérêt du simulateur de conduite pour la reprise de la conduite automobile en situation de handicap.

AIMS: To evaluate the value of our driving simulator in deciding whether or not to allow patients with physical and/or cognitive deficits to resuming driving and to analyze whether or not the medical expert's final decision is based more on the results of the driving simulator than those of the neuropsychological examination. METHODS: One hundred and twenty-three patients were evaluated with the driving simulator. Thirty-five of those with cognitive deficits also underwent a neuropsychological examination prior to the medical expert's decision on driving aptitude. In cases of uncertainty or disagreement, a driving assessment in real conditions was performed by a driving instructor. RESULTS: In cases of physical handicap, the medical expert's decision concurred with that of the occupational therapist. For brain-injured patients, there was a significant correlation between the neuropsychologist's opinion and that of the occupational therapist (kappa=0.33; P=0.01). However, the sensibility and specificity were only 55 and 80%, respectively. The correlation between an occupational therapy decision based on the driving simulator and that of the medical expert was very significant (kappa=0.81; P<0.0001) and the sensibility and specificity were 84 and 100%, respectively. In contrast, these values were lower (63 and 71%, respectively) for the correlation between the neuropsychologist's opinion and that of the medical expert. CONCLUSION: Our driving simulator enables the danger-free evaluation of driving aptitude. The results mirror an in situ assessment and are more sensitive than neuropsychological examination. In fact, the neuropsychologist's opinion often is more negative or uncertain with respect to the patient's real driving aptitude. When taking a decision on a patient's driving aptitude, the medical expert is more inclined to trust the results of the driving simulator.

REPAS, a summary rating scale for resistance to passive movement: item selection, reliability and validity.

PURPOSE: To establish: (i) item characteristics and item selection for the REPAS; (ii) internal consistency, inter-rater and test-retest reliability of the final REPAS version and its subtests; (iii) the association between the REPAS and selected other clinical scales of impairment and activity limitation. METHOD: Thirty-three neurological patients with central paresis. Two REPAS assessments with a one-week interval by two independent raters. Concurrent assessment of the Motricity Index, Box-and-Block test, Functional Ambulation Category, Timed walking, Barthel Index, Disability Rating Scale, Carer Burden Scale, and Hygiene Score. RESULTS: Twenty-six of 52 REPAS items fulfilled the item selection criteria. The final test version showed a high internal consistency, inter-rater and test-retest reliability (correlation coefficients: 0.87-0.97, no significant difference between raters or with test repetition). Reliability of the arm and leg subtests was substantial (correlation coefficients: arm subtest 0.63-0.98, leg subtest 0.56-0.96). REPAS scores were moderately associated with basic ADL competence and a carer's burden with arm or leg adductor spasticity. The REPAS, arm subtest scores, degree of arm paresis and gross manual dexterity showed a moderately high association. CONCLUSIONS: The Ashworth scale-based guidelines assured comparability of test administration and scoring. The REPAS is a reliable and valid summary rating scale for resistance to passive movement.

The effect of repetitive arm cycling on post stroke spasticity and motor control: repetitive arm cycling and spasticity.

This study's aims were (1) to test whether training on an arm ergometer improves motor performance, and (2) to develop a technique to quantify individual muscle spasticity. Nine patients with a stabilized hemisyndrome (in average 22 months after ischemic stroke in the territory of middle cerebral artery) underwent a 3-week training on an arm ergometer, 5 days/week. The patients were tested one week before training, at training onset, at the end of training and 2 weeks after training. Spasticity was quantified by (1) the Ashworth Scale of the elbow flexors and extensors, (2) the maximum active extension of the biceps, and (3) the minimum torque on the lesioned side during arm cycling. The data were standardized, pooled and a 2-way ANOVA revealed a decrease of the spasticity by the training (p=0.076). Similarly muscle force was evaluated by the Rivermead Motorik Assessment, the Motricity Index and the cycling force, and the range of active movement as the sum of the angles at a maximum shoulder flexion, shoulder abduction, elbow flexion and elbow extension. The training increased the force (p<0.01) and also the range of motion (p<0.05) significantly. The patients confirmed the clinical relevance of the results. The spasticity index - the relation between the muscle activity modulation on the normal and lesioned side - was shown to be a useful tool in quantifying individual muscle spasticity. It was concluded that cycling on an arm ergometer is a useful tool for rehabilitation.

Acute autonomic dysfunction contralateral to acute strokes: a prospective study of 100 consecutive cases.

Complex painful reflex syndrome is sometimes described in the chronic phase of stroke. Acute autonomic dysfunction (AAD), which is occasionally present in cases of acute stroke, has not been studied prospectively. The aim of the study was to investigate AAD on the hemibody contralateral to the lesion in the acute phase of stroke. One hundred consecutive patients (median age +/- interquartile range, 74 +/- 21; range 19-93; 51 women: 80 +/- 17 and 49 men: 70 +/- 17 years) in the acute phase of stroke were studied prospectively. Changes in skin temperature or coloration, diaphoresis, pain, or edema were noted in the first 3 days post-stroke. Associations between AAD and topography (cortical pre- and/or post-central, insular, corona radiata, basal ganglia, internal capsule, thalamus, and brainstem), age, gender, ischemic or hemorrhagic etiology, or the presence of sensorimotor deficits or ataxia were examined using the chi-squared or Fisher's exact test and logistic regression analysis. AAD was found in 71% of the patients and showed a significant positive association with the presence of a lesion in the post-central cortex (P = 0.037), internal capsule (P = 0.005), basal ganglia (P = 0.002), or insula (P = 0.011) and a negative association with the presence of a lesion in the brainstem (P = 0.004). Multivariate logistic regression analysis including all studied topographic variables showed that only brainstem lesions were significantly associated with a decreased risk of developing AAD (odds ratio = 0.08, 95% confidence interval: 0.01-0.69, P = 0.022). AAD was not associated with age, gender, the ischemic or hemorrhagic nature of the lesion, the side of lesion, hypertonic or hypotonic paresis, or hyperreflexia or hyporeflexia. AAD was found in association with sensory deficits (P = 0.001) and contralateral hyperkinesia (P = 0.004). Acute AAD is significantly more likely to occur in the presence of hemispheric lesions involving sensory pathways from the cortex to the internal capsule and insula and is significantly less prevalent in the presence of brainstem lesions.

Clinical scales for the assessment of spasticity, associated phenomena, and function: a systematic review of the literature.

PURPOSE: To characterise clinical assessment methods for spasticity and/or its functional consequences in clinical patient populations at risk to suffer from spasticity. METHOD: Systematic literature search and manual-based two-step review process of psychometric properties of clinical assessment scales for spasticity and associated phenomena, as well as of functional scales with an association with spasticity. Reviewed psychometric properties included internal consistency, interrater, intrarater as well as retest reliability, construct validity, ecological validity, and responsiveness. RESULTS: Until May 2003 electronic database searches established a reference pool of 4151 references of which 90 references contributed to the review objectives. An additional 20 references were identified by an informal reference search. Twenty-four clinical scales that assess spasticity and/or related phenomena as well as 10 scales for 'active function' and three scales for 'passive function' with an association with spasticity could be identified. Some evidence signals that a high interrater reliability of the Ashworth and modified Ashworth scales can be achieved, however not in all circumstances. For many scales, reliability data is, however, missing. This is especially true for test retest reliability. Information about construct validity can promote our understanding of what individual scales are likely to assess. Many scales have been able to document changes after therapeutic intervention. CONCLUSIONS: The collated evidence can guide our clinical decision about when to use which scale and can promote evidence-based assessment of spasticity and related clinical phenomena.

[Functional assessment of the hand in neurologic rehabilitation]. / Evaluation fonctionnelle de la main en réadaptation neurologique.

Functional evaluation of hand is essential in neurorehabilitation because it provides crucial information about capacities/incapacities of patients during their daily activities. Then therapists can plan realistic aims. This evaluation is usually devoted to occupational therapists, who have different tests and scales to measure the functions of hand. The movements and gestures of hands are so various and complex that no test is better than another. Here we select a few specific tests to evaluate hand functions and we present their advantages and interest in neurorehabilitation.

[Assessment of car driving skills in brain injured individuals]. / Evaluation des aptitudes à la conduite automobile chez le cérébrolésé.

Independent driving is considered as very important for a full independence and social integration of disabled people. In these patient with disabilities or handicaps, the driving skills must be carefully assessed, especially in presence of a moderate dysexecutive syndrome. A precise neurological and neuropsychological examination is usually necessary to evaluate aptitudes for driving. Standard neuropsychological tests are often limited to value the brain injury patients. At the moment, assessment on driving simulators really improves the opinion of medical experts, as they give qualitative and quantitative data on reproducible conditions. In fact, in more than 80% of cases, the tests on driving simulators allow to determine if the patient is able to drive or no, with or without a specially adapted vehicle. However, in a small percentage of cases, the evaluation of open-road driving by a driving instructor is necessary, proving that driving simulators will never take over from reality.

[Role of drugs in recovery from brain damage]. / Rôle des médicaments dans la récupération d'une lésion cérébrale.

The mechanisms that enhance recovery from brain lesion are more and more precise. The role of neurotransmitters and post-synaptic receptors are essential. Different drugs acting at the level of synapses are potentially useful but still few used in neurorehabilitation. The aim of this article is to review the drugs that can be prescribed in selected situation. In spite of encouraging results of numerous studies, a lot of questions remain and prove the need of large randomised studies to determine the real benefit of drugs in rehabilitation. Moreover, if the activation of neurotransmitters can improve recovery, all their antagonists will produce the inverse effect. Therefore, the choice of drugs in neurorehabilitation is essential.

[Cerebral venous thrombosis after lumbar puncture and intravenous steroids in two patients with multiple sclerosis]. / Thrombose veineuse cérébrale après ponction lombaire et stéroïdes intraveineux chez deux patients souffrant d'une sclérose en plaques.

Two patients affected with a multiple sclerosis developed cerebral venous thrombosis after lumbar puncture and treatment with intravenous methylprednisolone. In one case, the course was favorable. The second patient died in spite of intracerebral thrombolysis. The autopsy confirmed the diagnosis of cerebral venous thrombosis and multiple sclerosis. We discuss the relationship between lumbar puncture, steroid treatment and cerebral venous thrombosis.

Impact of cerebrospinal fluid PCR on the management of HIV-infected patients with varicella-zoster virus infection of the central nervous system.

Over a 2 year period, we identified five HIV-infected patients who presented with central nervous system infection caused by varicella-zoster virus, three with myelitits, and two with meningoencephalitis. All five patients were profoundly immunocompromised. Clinical presentation of these patients overlapped to a significant extent with diseases caused by other viruses, e.g. CMV. Indeed, in one case, a dual infection with CMV was diagnosed, but the respective role of each virus was ascertained by in situ hybridisation. At the time of CNS involvement, only one patient had active VZV cutaneous lesions, which were instrumental in diagnosing her condition. In contrast, PCR for VZV DNA in the CSF was helpful in making a diagnosis in the four other cases, one of which was confirmed by a post mortem. Of these five patients, two patients developed VZV disease while receiving oral acyclovir and had foscarnet treatment initiated when MRI demonstrated widespread lesions. They did not respond to antiviral therapy. The three other patients had intravenous acyclovir initiated at a time when no or limited parenchymal lesions were observed by MRI. Two of these three patients had VZV infection diagnosed solely on the basis of PCR: all three responded to treatment. Our data show that reactivation of VZV involving the central nervous system occurs frequently in the absence of cutaneous lesions. PCR of cerebrospinal fluid may help in making an early diagnosis which is probably a prerequisite for successful treatment of VZV infection of the CNS.

Autologous fat injection for soft tissue augmentation in the face: a safe procedure?

Autologous fat injection for soft tissue augmentation in the face is claimed to be a safe procedure. However, there are several case reports in the literature where patients have suffered from acute visual loss and cerebral infarction following fat injections into the face. Acute visual loss after injection of various substances into the face is a well-known complication of such interventions. We report two further patients who suffered from ocular and cerebral embolism after fat injections into the face. For the intravasation of fat particles there are three preconditions: well-vascularized tissue, fragmentation of parenchyma, and, especially, a local increase in pressure in the affected tissue. Fat injections into the face lead to an acute local increase in pressure in highly vascularized tissue. We assume that fragments of fatty tissue reach ocular and cerebral arteries by reversed flow through branches of the carotid arteries after they are introduced into facial vessels. The manifestation of fat embolism appears either immediately after the fat injection or after a latency period. Fat embolism can remain subclinical and may not be recognized, or the clinical features may be misinterpreted. To minimize the risk of such a major complication, fat injections should be performed slowly, with the lowest possible force. One should avoid fat injections into pretraumatized soft tissue, for example, after rhytidectomy, because the risk of intravasation of fat particles may be higher. Metabolic disturbances such as hyperlipidemia may also contribute to the clinical manifestation of fat embolism Routine funduscopic examinations after fat injections into the face could help to provide data for future estimation of the patient's general risk.

[Behavior disorders of neurological origin]. / Les troubles du comportement d'origine neurologique.

The modifications of behavior related to neurological diseases are various and important to be correctly diagnosed. The purpose of this article is to present the clinical features of main neuropsychiatric syndromes: depression, delusions, anxiety, obsessive-compulsive syndrome. The differential diagnosis is also developed. The appropriate treatment is discussed.