Graded Combined Aerobic Resistance Exercise (CARE) to Prevent or Treat the Persistent Post-concussion Syndrome

Purpose of Review

To review the growing body of indirect and direct evidence that suggests that exercise can be helpful for children, adolescents, and adults with persistent symptoms following a mild traumatic brain injury (mTBI).

Recent Findings

The direct evidence shows that graded exercise assessments are safe, and that aerobic exercise interventions are associated with improvement of multiple symptoms and other benefits, including earlier return-to-sport. The indirect evidence supports this approach via studies that reveal the potential mechanisms, and show benefits for related presentations and individual symptoms, including headaches, neck pain, vestibular problems, sleep, stress, anxiety, and depression. We document the forms of exercise used for the post-acute management of mTBI, highlight the knowledge gaps, and provide future research directions.

Summary

We recommend trialing a new approach that utilizes a graduated program of individually prescribed combined aerobic resistance exercises (CARE) if mTBI symptoms persist. This program has the potential to improve patient outcomes and add to the management options for providers.

     

The Perimenarche Syndrome (A Proposal)

Abstract: We present here two cases with depression and obsessional symptoms, in which the patients were 11–year-old girls just prior to the advent of menarche. Their clinical picture WM fairly different from the one which Deubsch, H., Jacobson, E. and Blos, P. described in their classical cases 80 far. In our cam the regression to preoedipal level was very prominent, that is, the rapprochement crieis-Like state (Mahler, M.S.) with transitional objects such M stuffed animals and dolls (Winnicott, D.W.) WM observed. It was believed that with such a background there were changes in the parent-child relationship in preadolescence which the premature physical growth among recent children had brought about, and changes in the concept of the mother and father which cultural vicissitudes had induced. It was also indicated that this kind of direct observation would contribute not only to the encouragement of the sound development in this period of life, but also the understanding and treatment of adolescent or adult cases.     

The Guillain-Barrè Syndrome (GBS)

A register of the Guillain-Barrè syndrome (GBS) has been started in Lombardy on February 1 1994, aiming at: 1) Making more correct estimates of the incidence and time and geographic trends of the disease; 2) Having a target population which serves for reference for analytical and experimental epidemiological studies; 3) Contributing to the validation of selected diagnostic procedures; 4) Implementing an audit of the diagnosis and treatment of GBS; 5) Collecting biochemical, hemathological and electrophysiological data to be stored in ad-hoc data-banks. In a pilot study undertaken during the period February 1 1994 – May 31 1995 a total of 109 patients (M 63; F 46) were recruited in 32 hospitals. The crude annual incidence rate of GBS was 0.92 per 100,000 population. Typical GBS had been diagnosed in 87% of cases, followed by atypical GBS (7%). The disease could not be classified according to the available criteria in 6% of cases. Electrophysiological features suggesting demyelination were present in 29% of cases; axonopathy was documented in 14%, and mixed patterns in 34%. Plasma exchange was the suggested treatment in 51% of cases, followed by immunoglobulins (24%) and steroids (23%).     

Systemic Inflammatory Response Syndrome (SIRS) Score Independently Predicts Poor Outcome in Isolated Traumatic Brain Injury

Introduction

Systemic inflammatory response syndrome (SIRS) is frequently observed after various types of acute cerebral injury and has been linked to clinical deterioration in non-traumatic brain injury (TBI). SIRS scores have also been shown to be predictive of length of stay and mortality in trauma patients. We aimed to determine the prognostic utility of SIRS present at admission in trauma patients with isolated TBI.

Methods

This was a 5-year retrospective cohort study of adults (≥18 years) with isolated TBI admitted to a Level II trauma center. The prognostic value of SIRS, total SIRS scores, and each SIRS criterion was examined by Χ ² and logistic regression analyses.

Results

Of the 330 patients identified, 50 (15.2%) met SIRS criteria. SIRS was significantly associated with poor outcome (P < 0.001). Relative risk of poor outcome was 2.7 times higher in patients with a SIRS score of 2 on admission (P = 0.007) and increased significantly to 6.5 times in patients with a SIRS score of 3 (P = 0.002). Logistic regression demonstrated SIRS and each criterion to be significant independent prognostic factors (SIRS, P = 0.030; body temperature, P = 0.006; tachypnea, P = 0.022, tachycardia P = 0.023).

Conclusion

SIRS at admission is an independent predictor of poor outcome in isolated TBI patients. These data demonstrate SIRS to be an important clinical tool that may be used in facilitating prognostication, particularly in elderly trauma patients. Future prospective studies aimed at therapeutic interventions to mitigate SIRS in TBI patients are warranted.

Level of Evidence

Prognostic, Level III.

     

Decision‐making for and impact of early immunomodulatory treatment: the Austrian Clinically Isolated Syndrome Study (ACISS)

Background and purpose: When to start disease‐modifying treatment (DMT) in patients with a clinically isolated syndrome (CIS) requires individual weighing of benefits versus possible burden of side effects and costs. How this occurs in a routine setting is barely known. The aim of the study was to investigate the decision‐making process regarding immediate or later DMT and the ensuing impact on CIS patients in Austria. Methods: Demographic and (para) clinical characteristics of 296 CIS patients were recorded in 29 multiple sclerosis (MS) centres, and the patients’ overall condition was rated on a visual analogue scale (VAS). Clinical follow‐up and VAS ratings were repeated at 6‐month intervals over 2 years. The decision for initiation of DMT was at the physician’s and patient’s discretion. Results: In 29% of patients, DMT was started within 3 months and this decision was independently associated with a T2‐lesion number ≥9 on MRI and a worse VAS rating by the physician. DMT initiation in the subsequent 6 months was additionally associated with the presence of oligoclonal bands and rarely occurred thereafter. Adapted to the clinical course, later treatment was associated with the highest rate of conversion to clinically definite MS and greatest disability after 2 years whilst never treated patients fared best. Patient VAS ratings significantly improved during follow‐up independently of treatment decisions. Conclusion: The management of Austrian CIS patients relies strongly on MRI findings and the physicians’ interpretation of the patients’ overall situation which, after 2 years, depends primarily on the course of the disease.     

The Schizotypic Syndrome Questionnaire (SSQ): Psychometrics, validation and norms

This paper examines the psychometric properties (reliability and factor structure) and validity (relationship with various self-report measures and SPEM dysfunction) of the SSQ or Schizotypic Syndrome Questionnaire, a 108-item inventory for the measurement of 12 prodromal or schizotypic symptoms present in Van Kampen's model of schizophrenic prodromal unfolding. This paper also provides normative data for the SSQ. The SSQ demonstrates adequate reliability and breaks down into three correlated factors: negative schizotypy, asocial schizotypy and positive schizotypy. Results further attest the construct validity of the instrument. Because of the implications of the SSQ model for the definition of schizophrenia, the instrument's three-dimensional factor structure and the nature of one of the factors are discussed in more detail.     

The Natural History of Myoclonic Astatic Epilepsy (Doose Syndrome) and Lennox-Gastaut Syndrome

Summary:  The purpose of this article is to present a short review of the natural history of myoclonic astatic epilepsy (MAE; Doose syndrome) and the Lennox-Gastaut syndrome (LGS). In the 1989 classification of the International League Against Epilepsy (ILAE, 1989), MAE and LGS were initially included in group 2.2: "Cryptogenic or symptomatic generalized epilepsies and syndromes." The subsequent classification of the Proposed Diagnostic Scheme for People with Epileptic Seizures and with Epilepsy (see Ref. 8 ) placed MAE in axis 3 in the "generalized epilepsy" group and LGS, severe myoclonic epilepsy of infancy (SMEI or Dravet syndrome) and atypical benign partial epilepsy/pseudo-Lennox syndrome (ABPE/PLS) in the "epileptic encephalopathy" group. The semiology of MAE and LGS and their differential diagnosis from SMEI and ABPE/PLS are described. Before the onset of SMEI, MAE, and ABPE/PLS, the development of the child is usually normal. In contrast, in LGS, development is frequently retarded at the onset, depending on the etiopathogenesis of the underlying brain disease. The course of MAE is highly variable with regard to seizure outcome (complete remission in some cases, persistent epilepsy in others) and cognitive development (normal or delayed). The course of LGS and SMEI is generally poor, both with regard to the epilepsy and to the cognitive development whereas the course and seizure outcome of ABPE/PLS is favorable; the patients will be seizure-free at puberty. However, the neuropsychological outcome is less favorable; most patients remain mentally retarded.     

Neuropsychological Findings: Myoclonic Astatic Epilepsy (MAE) and Lennox-Gastaut Syndrome (LGS)

Summary:  Purpose: To identify a specific neuropsychological profile associated with myoclonic astatic epilepsy (MAE) and Lennox-Gastaut syndrome (LGS).
Methods: Seven patients diagnosed with MAE and four patients diagnosed with LGS were selected from patients referred to our Child Neurology Unit. The patients were assessed both clinically (awake, sleep, Holter EEG, seizures frequency, and semiology) and neuropsychologically (IQ, language, attention, visuospatial and visuomotor abilities, and behavior). One representative case of each syndrome is presented here.
Results: The clinical picture of the MAE patient resembled that of an MAE condition associated with transitory epileptic encephalopathy. The neuropsychological findings suggest that electroclinical anomalies can temporarily affect cognitive and behavioral functioning. Early effective antiepileptic drug (AED) treatment was found to improve cognitive outcome. In contrast, LGS was associated with mental retardation, which persisted after seizure control.
Conclusions: At present, it remains difficult to delineate a precise neuropsychological profile associated with MAE and LGS. The cognitive outcome of MAE is variable and depends on the clinical pattern. With regard to LGS, the hypothesis of a genetic predisposition underlying both the epilepsy and the mental retardation is still valid. Alternatively, exposure to subclinical electrophysiological anomalies during a critical period of cerebral development may be responsible for the mental retardation. At the time the clinical manifestations appear, drug treatment, even if effective, would have only limited impact on cognitive outcome. However, early multidisciplinary intervention may help to improve behavior and communicative abilities, enhancing the quality of life of these children and their families.