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Objectives Survivors of severe traumatic brain injury have a great variety of impairments and participation restrictions. Detailed descriptions of their long-term outcome are critical. We aimed to assess brain injury outcome for subjects with traumatic brain injury in terms of the International classification of functioning, disability and health. Materials and methods Four-year follow-up of an inception cohort of adults with severe traumatic brain injury by using face-to-face interviews with patients and proxies. Results Among 245 survivors at 4 years, 147 were evaluated (80% male, mean age: 32.5 ± 14.2 years at injury); 46 (32%) presented severe disability, 58 (40%) moderate disability, and 40 (28%) good recovery. Most frequent somatic problems were fatigue, headaches, other pain, and balance. One quarter of subjects had motor impairments. Rates of cognitive complaints ranged from 25 to 68%, the most frequent being memory, irritability, slowness and concentration. With the Hospital Anxiety and Depression Scale, 43% had anxiety and 25% depression. Overall, 79% were independent in daily living activities and 40 to 50% needed help for outdoor or organizational activities on the BICRO-39. Most had regular contacts with relatives or close friends but few contacts with colleagues or new acquaintances. Subjects spent little time in productive activities such as working, studying, looking after children or voluntary work. Quality of life on the QOLIBRI scale was associated with disability level (P Conclusion Management of late brain injury needs to focus on cognitive difficulties, particularly social skills, to enhance patient participation in life.

Background Cognitive impairment (CI) is frequent in patients with multiple sclerosis (PwMS) and could negatively affect family social and vocational activities. Detecting CI is clinically relevant, so the emerging question is the strategy for assessing cognition in MS. Objective An update on cognitive assessment in PwMS with use of standard neuropsychological (NP) tests and ecological tools. Results The minimal cognitive assessment in MS should include at least NP tests assessing information processing speed (IPS) and verbal and visuospatial episodic memory. The IPS could be easily and quickly evaluated with symbol digit substitution tests by using paper for the oral version of the Symbol Digit Modalities Test or a laptop for the Computerised Speed Cognitive Test. The comprehensive NP battery must be performed by a qualified neuropsychologist to adequately characterize the extent and severity of CI in PwMS. The quiet and controlled environment used for this standardized assessment could be a limitation for generalizing the results because it does not reflect real daily life conditions. Thus, this context could decrease the ability to detect some cognitive deficits that could occur only in more complex situations. Thus, ecological evaluation seems a complementary and promising approach for detecting cognitive abnormalities in daily activities. Conclusion Recent efforts have been made to detect and characterize cognitive deficits in PwMS. Some IPS and episodic memory NP tests have been validated in MS and should be proposed to patients in the clinical setting. Besides NP tests, ecological tools are becoming important for detecting cognitive dysfunction in everyday-like conditions. Further research is needed to validate relevant tools for monitoring cognition in MS and the ability to detect clinically meaningful change in longitudinal studies.

Introduction Intramuscular injection of botulinum toxin (BoNTA) is one of the primary treatments for focal spasticity. This treatment is considered costly and the level of reimbursement by health insurance has been decreasing in many countries for several years. The aim of this study was to determine the real cost of treating spasticity with BoNTA and to compare this with the level of reimbursement by the national health insurance in France in 2008 and with a new fee, specific to the injection of BoNTA in ambulatory services. Method A single-center, retrospective study using the 2008 database from a French secondary-care day-hospital unit (treating spasticity in adults with sequelae of stroke, multiple sclerosis or traumatic brain injuries). The level of reimbursement by the French ministry of health for BoNTA treatment for adults with spasticity constituted the “calculated cost” and corresponded to the hospital's “budget”. The “real cost” (incurred by the hospital) included the sum of staffing and material costs as well as the number of toxin vials used. The calculated costs for 2009 and 2013 were based on the levels of reimbursement during those years. The difference between real and calculated cost for 2009 and 2013 was estimated considering that the real cost of 2008 was stable. Results In 2008, 364 patients received BoNTA, resulting in 870 day-hospital admissions. The calculated cost was 459,056 €/year and the real cost was 567,438 €/year (equivalent to 4.27 €/day/patient). The total budget deficit (hospital income minus hospital costs) was 108,383 €. The deficit was estimated at 222,892 € in 2009 and 241,188 € in 2013. Conclusion The daily cost of BoNTA treatment for spasticity is reasonable; however, because of the level of reimbursement by the national health insurance in France, the treatment is costly for French hospitals.

Objective Patients with heart diseases are encouraged to engage in regular physical activity (PA). However, several barriers hamper the implementation of a physically active lifestyle in a sustainable way. The objective of this study was to assess the medium-term impact of a physical activity seminar with motivational counseling on barriers to physical activity and PA in coronary artery disease (CAD) patients. Material/patients and methods We conducted a seminar for CAD patients, consisting of 4 successive days of physical activities (Nordic walking, Tai Chi, Qi Gong…) with initial motivational interview and personalized counseling at the end of the stay. Participants completed the BArriers to Physical Activity in Coronary heart disease (BAPAC) questionnaire at the beginning and end of the seminar and 3 months later. They also completed the Dijon Physical Activity Score (DPAS) at the beginning of the seminar and 3 months later. Results Eleven patients participated in the seminar (9 men, 2 women, 63 ± 8.4 years), had CAD diagnosed for 5.8 ± 4 years and were predominantly overweight/obese (mean BMI: 29.3 ± 3 kg/m2). No adverse events were reported. At the beginning of the seminar, the average BAPAC score was 29.5 ± 8/60 with an average DAPS of 20.8 ± 3/30. At the end of the seminar, the mean BAPAC score was lower: 23.8 ± 7/60 (P Discussion, conclusion A physical activity seminar with motivational interviews and personalized counseling on PA quickly reduces the barriers to physical activity in CAD patients, measured by the BAPAC questionnaire. Beneficial effect persists 3 months after the intervention. However, these changes are not associated with a significant increase in PA measured by the Dijon physical activity score. Further studies are needed to assess the sensitivity to change of the BAPAC questionnaire and the long-term correlation between the PA barriers removal and the increase in PA.

Introduction/Background The variety of consequences of traumatic brain injuries (TBI) constitutes a challenge in defining priorities of care planning. Our aim was to assess care utilization and unmet care needs in a homogeneous well-described sample of patients with long-term TBI. Material and method The Paris-TBI inception cohort recruited adults with severe TBI (initial GCS Results Mean age was 43 years, mean Glasgow Outcome Score-Extended (GOSE) was 6 (moderate disability). Care utilization was important, with 20% having physiotherapy, 10% speech therapy, 2% occupational therapy, 6% psychotherapy. In the past year, 7% had been hospitalized; mean number of visits to general practitioners was 4.2. For everyday activities, 6% had professional help, 67% had help from a proxy. Most care needs were cited as unmet by 10 to 30% of the sample. Unmet needs for information on TBI to patients, to proxies, and for coordination of services were each cited by more than 50%. Unmet need for psychological help was cited by 46%. Mainly expressed barriers to care access were lack of information (52%), and waiting times (27%). Mean number of unmet needs per patient was 8 (min–max: 3–12). Number of unmet needs was not significantly related with age and gender. It was significantly associated with GOSE (rho = −0.5, P Conclusion Such results can help address the needs of the brain injury population. A priority seems to be to improve the information offered to patients and proxies.

Introduction/Background Stroke survivors are encouraged to participate in regular physical activity (PA). However, the vast majority of patients do not practice PA as recommended and numerous “barriers” prevent the patient from getting back to a physically active lifestyle. Objective To develop and validate a self-reported questionnaire assessing the barriers to 6 physical activity (PA) among stroke survivors. Material and method Population was stroke survivors with no to moderate disability (Rankin score 0–3, stroke > 3 months). In part 1, semi-structured interviews were performed to identify potential barriers to PA, which were then selected by a group of experts and grouped in a BAPAS scale. In part 2, stroke survivors filled out a personal information questionnaire and the BAPAS scale. An item selection process and principal component analysis (PCA) were carried out, and internal consistency was evaluated by Cronbach's α. Concurrent validity was established through correlation between the BAPAS SCE and the modified Rankin Scale. Test-retest reliability was evaluated with the intraclass coefficient (ICC). Results In part 1, 37 subjects reported 43 “barriers” of which 27 were selected in an initial BAPAS scale. In part 2, 109 subjects (63% men, 72% ischemic stroke, mean age 60.6 years) were included. Item selection process created a 14-item BAPAS scale suitable for factor analysis (KMO = .82) with two sub-scales (behavioral and physical). The maximum score was 70 (highest barriers). Internal consistency was high (α = .85) and a strong correlation with the modified Rankin Scale was found (r = .65, P Conclusion We developed and validated the BAPAS scale to assess barriers to PA in stroke survivors. This scale could help to personalize strategies promoting physically active lifestyles after stroke.

Introduction/Background Persons with a traumatic brain injury (TBI) are frequently involved in a litigation with claim compensation because another person was at fault for causing the accident. However, settling a lump sum is a complex and multi-determined process that is related to patients’ past, present and future losses and needs, but also to external factors (such as the attorney's skills, the jurisdiction specificities, the TBI expert involved during court proceedings). We report preliminary results about the final lump sum and long-term TBI outcomes. Material and method Prospective study of severe TBI patients injured in the Parisian area in 2005–2007. Questions regarding involvement in a litigation and lump sum were asked 4- and 8-years after the TBI concurrently with 4- and 8-years outcomes. Results Among 147 out of 160 patients that answered to the question about litigation, 80 were not involved and 67 were litigants. The litigation was over after 4 and 8 years for 25 and 32 people respectively, and still in progress for 10 of them. The final capital awarded was reported in 38 people and amounted €0 for 1 person and a mean €292 653 (SD = 436 334; minimum = 1500 - maximum = 2,000,000) for the others. No difference in capital amount was found according to gender and working status. In separate correlation, capital was found to correlate with 4/8 yrs Glasgow Outcome Scale - extended (GOS-E) score, Dysexecutive Questionnaire (DEX) score, functional status and caregiving time, but not with age, years of study, mood, caregiver burden. Conclusion Among a wide range of factors that play a role in the financial settlement, a higher capital seems to be related to long-term severe impairment in patients, with the notable exception of working status.

Introduction/Background Traumatic Brain Injury (TBI) is a leading cause of acquired persistent disabilities. Sequalae increase with TBI severity. As young adults are particularly exposed, TBI represent an important health and economic burden. However, long-term outcome is poorly described in scientific literature. Material and method Prospective observational study of an inception cohort of adult patients with severe traumatic brain injury in the Parisian area (Paris-TBI). Outcome description assessed with face-to-face interview 8 years after TBI. Results Five hundred and four patients were included between 2005 and 2007, 257 were discharged alive from acute care. At 8-year follow-up, 261 of initial 504 were deceased, 128 patients were lost to follow-up, 22 refused to participate, 86 were finally evaluated. Mean age was 41.9 (SD 13.6), 79% were male, median initial Glasgow Coma Scale Score (GOS) was 6. Age, sex, initial severity did not differ between evaluated patients and lost to follow-up who were more frequently students or unemployed. Detailed information on impairments, functional status, activities were obtained. 5% were institutionalized. 11% suffered seizure since TBI. According to GOS-Extended scale score, 30% remained severely disabled, 41% moderately disabled, 29% had a good recovery. The most frequent somatic disorders concern balance (47.5%), motricity (31%), headaches (36%) and were less frequent than cognitive complaints (Memory 71%, Slowness 68%, Concentration 67%). On Hospital Anxiety and Depression scale, 16% had a score > 10 for anxiety and 18% for depression. At 8 years, 12% worked temporarily after TBI 4, 45% had a job. Of those 37%, declared a salary loss since TBI. Among those who did not returned to work, 89% declared that was because of TBI consequences. Conclusion These results from an inception cohort highlight that adult patients frequently suffer cognitive and somatic disorders after severe TBI. Long after the TBI, these impairments still interfere with social integration and participation.

IntroductionTraumatic brain injury (TBI) frequently leads to cognitive and behavioural disorders interfering with everyday life and work, despite the absence of focal lesions on clinical images acquired after injury. The aim of this study is to use magnetic resonance imaging (MRI) to examine whether volumetric alterations measured voxel by voxel in the whole brain could explain these cognitive and behavioural disorders.MethodsEight adults with severe TBI (GCS≤8) but without focal lesions on the CT scan were included. Patients had normal intellectual abilities (PM38) but abnormal behaviour (Lhermitte's scale). These 8 patients and 17 age-matched controls performed an episodic memory task (RL-RI-16 items) as well as classical and ecological executive tasks. All participants also underwent a volumetric T1-weighted MRI at 1.5T. Grey and white matter volumes were compared between patients and controls using the Voxel Based Morphometry (VBM5) toolbox in the Statistical Parametric Mapping (SPM) software.ResultsPatients exhibited abnormal results on both the episodic memory and executive tasks. Regarding brain volume, between-group comparisons (P

Opinion/feedback Disabled people see, as the general population, increased life expectancy. The advanced age of the disabled person is reflected by two characteristics: the occurrence of new disabilities related to age per se but also a possible increase of previous impairments. This summation of the effects must be known, recognized and anticipated. Following the work coordinated by Patrick Gohet, we investigated the responses to date on the following topics included in the national report: anticipation of the phenomenon, prevention of consequences, marking the onset of the effects of advanced age, accompanying the installation of the effects of this advanced age. Are questioned, in addition to people living at home, the nursing homes of Calvados, Manche and Orne: 16 foster homes (FAM), 25 specialized care homes (MAS) 43 establishments and services through work (ESAT) and lodging homes, but also the accommodation establishments for dependent elderly (nursing homes: about 220 structures) unused to accommodate guests with disabilities. The purpose of this work is to create new cooperation by removing obstacles of each home, adapting procedures, assessments, allowing the coordination between actors in the medical, nursing home, the training of professionals, the interaction between the different administrations beyond their specific missions.

CO27-002-f Pertes de vue d’une cohorte de patients traumatises crâniens et contexte social. L’etude PariS-TBI C. Jourdan a,∗, E. Bayen b, S. Barhami a, I. Ghout c, E. Darnoux c, S. Azerad c, P. Pradat-Diehl b, A. Ruet a, C. Vallat-Azouvi a, J.J. Weiss d, P. Aegerter c, P. Azouvi e a Assistance publique–Hopitaux de Paris, hopital Raymond-Poincare, Garches, France b Assistance publique–Hopitaux de Paris, hopital Pitie-Salpetriere, Paris, France c Unite de recherche clinique, hopital Ambroise-Pare, Assistance publique–Hopitaux de Paris, Paris, France d Centre ressources francilien du traumatisme crânien, Paris, France e Universite de Versailles – Saint-Quentin-en-Yvelines, France ∗Auteur correspondant.

Introduction Since May 2002, hospital care for Persistent Vegetative State (PVS) or Minimally Conscious State (MCS) patients in France are structured in dedicated units: PVS/MCS units. The aim of this survey is to analyze the current situation after 10 years. Method In 2012, the 135 health institutions with PVS/MCS units were contacted to fill out a questionnaire with information about health facilities, human resources, patients care pathways and characteristics. Results Fifty-one institutions (38%) answered the questionnaire. The PVS/MCS units had an average of 8.3 authorized beds (max–min: 4–19), for 8.1 available beds and a 97% bed occupation rate. They admitted on average 21 patients since their creation. Important disparities regarding staff resources existed between these Units. With regard to the 348 patients documented (mean age: 48.2; min: 13; max: 82), 36% were in PVS ans, 51% were in MCS, 10% had left MCS. Arousal state improved since admission for 25% and decreased for 1%. Initial pathology was traumatic brain injury for 35%, anoxic brain injury for 27%, stroke for 22%. Initially, 70% of the patients had quadriplegia, and 30% had hemiplegia, 88% of them had orthopedic complications. Among the patients, 45% had a tracheotomy and 92% had a digestive stomy. Mean length of stay was 4.5 years. The annual mortality rate was below 5%. Finally, 12% awaited another living unit because their state of consciousness had improved. Discussion/Conclusion Structured hospital care for Persistent Vegetative State (PVS) patients or Minimally Conscious State (MCS) in France appears adequate to meet the quality objectives fixed by the May 3rd, 2012 commission regarding health facilities, admission criteria and health care. Patients require important care and staff resources. Patient discharge from these units is frequently a problem in case of improvement because of a lack of adequate living places.