Traumatic brain injury rehabilitation, the programs applied in French UEROS units, and the specificity of the Limoges experience.

First created in 1996, the French evaluation, retraining, social and vocational orientation units (UEROS) now play a fundamental role in the social and vocational rehabilitation of patients with brain injury. As of today, there exist 30 UEROS centers in France. While their care and treatment objectives are shared, their means of assessment and retraining differ according to the experience of each one. The objective of this article is to describe the specific programs and the different tools put to work in the UEROS of Limoges. The UEROS of Limoges would appear to offer a form of holistic rehabilitation management characterized by the importance of psycho-education and its type of approach towards vocational reintegration.

Preliminary questions before studying mild traumatic brain injury outcome.

OBJECTIVES: To point out from the literature the issues in mild traumatic brain injury outcome. METHODOLOGY-RESULTS: The literature review allows to point out several different factors involved in the difficulty to study mild traumatic brain injury: mild traumatic brain injury definition, postconcussional syndrome definition, diagnosis threshold, severity and functional symptoms outcome, neuropsychological tests, unspecific syndrome feature, individual factors, confounding factors and treatment interventions. DISCUSSION-CONCLUSION: The mild traumatic brain injury outcome study is complicated by the definitions issues and especially their practical use and by the multiplicity and the intricate interrelationships among involved factors. The individual outcome and social cost weight is widely emphasized for an event still considered as medically trivial. The well-ordered preventive interventions necessity and the targeted treatment programs need for the persisting postconcussive symptoms complete our critical review.

[French version of structured interviews for the Glasgow Outcome Scale: guidelines and first studies of validation]. / Version française de l'entretien structuré pour l'échelle de devenir de Glasgow (GOS): recommandations et premières études de validation.

OBJECTIVES: The Glasgow Outcome Scale (GOS) is the most widely used outcome measure after traumatic brain injury. The GOS's reliability is improved by a structured interview. The two aims of this paper were to present a French version of the structured interview for the five-point Glasgow Outcome Scale and the extended eight-point GOS (GOSE) and to study their validity. METHODS: The French version was developed using back-translation. Concurrent validity was studied by comparison with GOS/GOSE without structured interview. Inter-rater reliability was studied by comparison between assignments made by untrained head injury observers and trained head injury observers. Strength of agreement between ratings was assessed using the Kappa statistic. RESULTS: The French version and the guidelines for their use are given in the Appendix. Ratings were made for 25 brain injured patients and 25 relatives. Concurrent validity was good and inter-rater reliability was excellent. CONCLUSION: Using the structured interview for the GOS will give a more reliable assessment of the outcome of brain injured patients by French-speaking rehabilitation teams and a more precise assessment with the extended GOS.

[The psychopathology of the unawareness of cognitive impairments and behavioral limitations in traumatic brain-injured patients]. / Psychopathologie de la méconnaissance des troubles cognitifs et comportementaux des traumatisés crâniens sévères.

OBJECTIVE: To explore the unawareness of cognitive impairments and behavioral limitations using a psychopathological approach. PATIENTS AND SETTING: Fifteen patients with chronic severe TBI. Outpatient TBI rehabilitation programs in three different centers. MAIN OUTCOME MEASURES: Case reports. The data from semi-structured interviews with the patients and their families, at least six months after the accident, were compared with data supplied by the Patient Competency Rating Scale (PCRS) and the Neurobehavioral Rating Scale-Revised (NRS-R). RESULTS: Nine patients demonstrated unawareness of their limitations according to the PCRS (Group I), whereas six did not (Group II). Psychic phenomena specific to patients of group I were found. Some of these were specific to brain injury, such as the lack of representation of cognitive impairments and behavioral limitations or the difficulty to integrate the brain-injury into one's psychic space. Others were not specific to brain injury such as mourning process difficulties, personality characteristics, defense mechanisms. Several psychic phenomena coexisted in the same patient. CONCLUSION: This study shows the complexity of unawareness of cognitive impairments and behavioral limitations and makes future clinical and theoretical definition indispensable.

[Psychological aspects of awakening from severe brain injuries: a theoretical approach]. / Aspects psychiques de l'éveil des traumatisés craniens sévères: une approche théorique.

As they take care of brain injured patients from coma to socioprofessional return, the authors suggest a psychopathological pattern of coma and awareness. Psychoanalytics concepts of need, request, wish, object a, fantasy and "Jouissance" allows reflexion on psychic events of awareness and suggest the way of taking care of these patients. Recovery from brain injury combines neurological recovering with nursing people's wish and questions again about the peculiar structure of the human being.

[Prospective study of the analgesic action of clomipramine versus placebo in refractory lumbosciatica (68 cases)]. / Etude prospective de l'action antalgique de la clomipramine versus placebo dans les lombosciatalgies rebelles (68 cas).

The authors sought to determine the analgesic activity of clomipramine (CMP) versus placebo, efficacy and side-effects according to the time of administration, long term clinical results and the relationship between plasma levels and analgesic effect. This double-blind randomised trial involved the infusion of 250 ml of glucose solution morning and evening versus placebo. CMP was administered at progressive doses for 8 days (maximum dosage 75 mg), either in the morning at 8 a.m. or in the evening at 6 p.m. Sixty eight patients accepted to be treated, all suffering from low back pain with or without sciatica. Maintenance treatment at the dose of 75 mg/day was then administered. CMP had a statistically significant analgesic action independent (rapidity of action) of its antidepressant activity. CMP was more effective and better tolerated (sedative and tranquilizer effect) in the evening. Long term results were poor (75% of cases). There was no link between plasma levels and clinical response. The authors noted that the analgesic activity of CMP was rapid, but for a duration limited to the short term and that this efficacy compared with the quite good results obtained with the placebo could be explained by a possible methodological bias (patients hospitalised and treated by intravenous infusions). The finding that CMP was better tolerated in the evening, without any loss of efficacy, is a positive feature (chronotherapeutic trial). Poor long term results could be partially explained by side-effects (66%). There was no relationship between analgesic effect and plasma levels.

[Psychologic and human implications of intensive care and rehabilitation of severe head injuries patients]. / Les enjeux psychiques et humains de la réanimation et de la réhabilitation des traumatisés crâniens sévères.

Consequences which are involved in intensive care and rehabilitation of severely head injuries patients seem to be numerous, variable in different times and different situations. However, the authors, for more than ten years, have taken care of severely injured patients from coma to socio-professional reinsertion, and so, it allowed them to concentrate their interest to that main point: it is necessary to make a place to the patient as a desiring patient, and not only as brain injured patient who needs medical care, medical knowledge and who needs be repaired. So the Psycho-Rehabilitation Unit works this way, to allow a new intra and intersubjective homeostasis, in spite of injury and sequellae.