Epidemiological data indicate that patients who experience a traumatic brain injury (TBI) have an elevated risk of developing a substance use disorder (SUD), but the underlying neurobiological connections remain unclear. To further understand the relationship between TBI and SUD, we investigated the effects of TBI on the abuse-related effects of oxycodone in preclinical models. Our evaluation utilized a lateral fluid percussion injury of moderate severity in adult male Sprague-Dawley rats. In the first aim, we tested the hypothesis that moderate TBI increases the risk for relapse to an opioid use disorder as measured by reinstatement of lever-pressing behavior following extinction in an intravenous oxycodone self-administration procedure. In the second aim, we tested the hypothesis that moderate TBI increases physiological dependence to oxycodone as measured by decreases in food-reinforced lever-pressing behavior and increases in other withdrawal behaviors in both precipitated withdrawal and spontaneous withdrawal. In tests for self-administration, brain-injured subjects, relative to non-injured subjects, showed no significant differences in the number of oxycodone-reinforced sessions required to meet stable maintenance criteria for lever-pressing behavior. Likewise, brain-injured subjects showed no significant differences in the number of non-reinforced sessions to meet extinction criteria for lever-pressing behavior relative to non-injured subjects. In tests for reinstatement, non-injured subjects reinstated responding under oxycodone-associated cue- and oxycodone prime-induced conditions, however, brain-injured subjects did not reinstate lever-pressing behavior under any conditions. In tests for physical dependence, brain-injured subjects showed no significant differences from non-injured subjects with regards to their mean withdrawal scores or food-reinforced lever-pressing behavior. Overall, these data suggest that brain-injured patients no significant pre-morbid history of opioid abuse are at a lesser risk of relapse to opioid use disorders. Moreover, the characteristic withdrawal syndrome in opioid-dependent patients may not contribute to continued opioid abuse to a greater degree in brain-injured patients than compared to non-injured patients.

Title: Psychosocial consequences of traumatic brain injury. Their impact on the patient's family. Author: František Jira Institution: Cathedra of psychology FF UK in Prague Supervisor: doc. PhDr. Petr Kulišťák, Ph.D. Number of pages: 116 Key words: traumatic brain injury psychosocial consequences family focus group grounded theory The submitted diploma thesis deals with the psychsocial consequences (related to the life among people) of traumatic brain injury. The main theme of the diploma thesis is the impact of these effects on the patient's family. The work consists of a theoretical and an empirical part. The theoretical part is divided into four spheres - neuroanatomy and pathology, brain injury, psychosocial consequences and rehabilitation. In the empirical part the author use a qualitative research approach to deal with the impact of psychosocial consequences after the traumatic brain injury to the patient's family. The research took place in association Cerebrum and Ústřední vojenská nemocnice Praha, it was conducted by the method of focal groups. The method of grounded theory was used for the consequent analysis. The result is an understandable processing of the extensive topic of the psychosocial consequences for people after brain injury. The work provides the detailed view of typical...

Traumatic brain injury (TBI) caused by traffic and fall accidents, sports-related injuries and violence commonly results in life-changing disabilities. Cognitive impairments following TBI may be due to disruption of axons, stretched by the acceleration/deceleration forces of the initial impact, and their surrounding myelin in neuronal networks. The primary injury, which also results in death to neuronal and glial cells, is followed by a cascade of secondary injury mechanisms including a complex inflammatory response that will exacerbate the white matter injury. Axons are supported and protected by the ensheathing myelin, ensuring fast conduction velocity. Myelin is produced by oligodendrocytes (OLs), a cell type vulnerable to many of the molecular processes, including several inflammatory mediators, elicited by TBI. Since one OL extends processes to several axons, the protection of OLs is an important therapeutic target post-TBI.  During development, OLs mature from oligodendrocyte progenitor cells (OPCs), also present in the adult brain. The aim of this thesis was to investigate white matter pathology, with a specific focus on the OL population, in experimental and clinical TBI. Since the inflammatory response may contribute to OL cell death and OPC proliferation, neutralization of interleukin-1β (IL-1β) was investigated. The lateral and central fluid percussion injury models were used in mice and rats where memory, learning and complex behaviors were investigated by two functional tests. Brain tissue, surgically resected due to life-threatening brain swelling or hemorrhage, from TBI patients was also investigated. Axonal injury, myelin damage, microglia alterations and OPCs and OL cell death were investigated by immunohistochemical techniques. In focal and diffuse experimental TBI, OL cell death was observed in important white matter tracts. OL cell death was accompanied by myelin damage, axonal injury and presence of microglia as well as an increased number of OPCs in both the experimental and human setting. OPCs were found to proliferate in diffuse TBI in mice where both complex behavioral changes and impaired memory were observed. Neutralization of IL-1β normalized and improved these behavioral alterations and also lead to a preserved number of mature OLs although without influencing OPC proliferation. The results provided in this thesis indicate that white matter pathology is a key component of the pathophysiology of TBI. The OPC proliferation may influence regeneration post-injury and might be an important future therapeutic targets for TBI. The present studies also suggest that treatment strategies targeting neuroinflammation may positively influence behavioral outcome and OL cell death in TBI. / <p>(Faculty of Medicine)</p>

Home environment should be accesible, barrier free and safe for people with disabilities. There is one possibility how to achieve these conditions the possibility is to let an occupational therapist to assess your home environment. The main parts of occupational therapy are: evaluation of home environment, suggesting of reconstrucitons needed and recommendations about helping aids. Environment is according to the International Classification of Functioning, Disability and Health one of the factors which are very important. The main goal of this diploma thesis was to design new evaluation of home environment of people with acquired brain injury made according to the International Classification of Functioning, Disability and Health. Partial goals were: to identify barriers of home environment, to determine facilitators which are already existing and to suggest helping aids and reconstructions if it is necessary. All for achieving the best quality of self-sufficiency of client. Theoretical part is about acquired brain injury, International Classification of Functioning, Disability and Health, issues of evaluation of home environment and assessments which are already existing. Practical part describes the proces of creation of evaluation and intervetions in home environment. Both described by case...

<div>Recent advances in Magnetic Resonance Imaging (MRI), a noninvasive imaging technique, have spurred the exploration of poorly understood physiological phenomena <i>in vivo</i>. Applications of MRI vary greatly, from anatomical evaluation to complex functional analysis. The body of this dissertation presents four applications of MRI: 1) investigation of a novel traumatic brain injury (TBI) biomarker, 2) analysis of position-specific head acceleration events on neurometabolic profiles in high school football athletes, 3) the first reporting of neurometabolic changes in middle school football athletes, and 4) a novel application of diffusion-weighted imaging (DWI) to characterize implantable drug-delivery depots (Appendix A).</div><div> </div><div>Magnetic resonance spectroscopy (MRS) is an MRI method used to evaluate the metabolic profiles of tissues. Certain brain metabolites (N-acetyl aspartate, <i>myo</i>-inositol, choline, creatine, and glutamate/glutamine) offer unique information regarding brain homeostasis following TBI. When coupled with additional metrics, such as head acceleration events recorded during collision-sport participation, the mechanisms of neurophysiological changes can be further elucidated. Here, player position-specific neurometabolic changes were evaluated in high school and middle school football athletes. Striking differences were noted between linemen and non-linemen as well as high school and middle school athletes.</div><div> </div><div>However, in most clinical cases of TBI, information regarding head acceleration events is unknown and baseline scans are not available.Therefore, it is critical to evaluate candidate biomarkers which increase solely in response to injury. Acrolein, a toxic reactive oxygen species, has been shown to increase following injury to the central nervous system in animal models. Hence, acrolein is a prime TBI biomarker candidate and has been investigated using nuclear magnetic resonance and MRS at 7 Tesla.</div><div> </div><div>Applications of MRI are not limited to the brain, or even tissues. Studies have reported that up to 50% of patients fail to take their medications correctly - resulting in disease progression and medication waste. <i>In situ</i> forming implants (ISFIs) offer an alternative to oral dosage regimens but have not been validated <i>in vivo. </i>Using DWI, ISFIs can be characterized noninvasively and their design can be refined, ultimately improving patient outcomes.</div><div> </div><div>Taken together, MRI is powerful tool that can be used to investigate a wide range of physiological questions. Chapters 2-4 will emphasize efforts to improve TBI diagnostics and better understand neurometabolic changes in youth football athletes. Appendix A offers insights into the DWI-guided characterization of <i>in situ</i> forming implants.</div>

Traumatismos craniencefálicos (TCE) constituem a primeira causa de morte de vítimas de trauma que chegam vivas ao atendimento hospitalar, sendo causados, na sua grande maioria, por quedas e acidentes automobilísticos. Além da mortalidade, esses eventos produzem um grande número de casos de incapacidades temporárias ou permanentes, de modo especial em indivíduos jovens. O presente trabalho teve por objetivo estudar características clínicoepidemiológicas dos pacientes com TCE de todas as etiologias atendidos na Unidade de Emergência do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto (UEHCFMRP) no período de 1º de janeiro de 2010 a 31 de dezembro de 2016 (componente 1) e a qualidade de vida das vítimas de TCE com alta hospitalar entre os dias 1º de janeiro e 31 de julho de 2015 (componente 2). Para o componente 1, foram analisadas informações de 3.775 pacientes com TCE notificados no banco de dados do Núcleo de Vigilância Epidemiológica Hospitalar. Após consentimento na participação, foi realizado o componente 2, em que 29 indivíduos foram visitados para a aplicação de instrumentos específicos para os objetivos do estudo, (SF-36, Escala de AVD de Lawton e Brody, HADS, FQ-VP, Questionário referente ao processo reabilitativo). Em todos os anos estudados, TCE foram predominantes em homens, brancos, jovens, solteiros, de baixa escolaridade e profissionalmente ativos. Em números absolutos, os acidentes de tráfego terrestre continuam sendo os mais frequentes mecanismos causadores de TCE. Após um ano de trauma a maioria das pessoas continua sem emprego e não incluída socialmente, e percebem comprometimento de sua qualidade de vida. Os resultados deste estudo permitem conhecer evidências sobre a previsibilidade do contexto da ocorrência do TCE, bem como das alterações de vida que ele promoverá ao traumatizado, independentemente do seu grau de gravidade. Tomadas em conjunto, essas informações podem nortear a implementação de estratégias preventivas que possam mitigar esse grave problema de saúde pública. / Traumatic brain injuries (TBI) are the leading cause of death of trauma victims who are admitted to a hospital in the most severe cases due to falls and automobile accidents. In addition to mortality, these events produce a large number of cases of temporary or permanent disability, especially among young individuals. Such people undergo long and expensive rehabilitation processes, and typically require special adaptations and equipment, as well as teams of specialized staff. Still, most of them cannot, after the medium term, manage their own lives and re-start their daily activities and professional and school commitments. This study aimed to evaluate clinical and epidemiological characteristics of patients with TBI of all etiologies admitted to the Emergency Unit of Hospital das Clínicas of the Ribeirão Preto Medical School of (UE-HCFMRP) between January 1st, 2010 and December 31, 2016 (component 1) and quality of life among TBI victims between 1st January and 31st July 2015 (component 2). For component 1, information from 3,775 patients with TBI (reported to) was analyzed in the database of the Center for Hospital Epidemiological Surveillance. After consent to participation, component 2 was performed, in which 29 individuals were visited for the fullfilliing of specific tools for the study goals (SF-36, Lawton and Brody ADL Scale, HADS, FQ-VP, Reference Questionnaire to the rehabilitation process). In the whole studied interval, TBI were predominant among men, whites, youngsters, single, low education and professionally active people. In absolute numbers, traffic accidents continue to be the most frequent mechanism causing TBI. One year after hospital discharge, most people remain unemployed and socially excluded, and perceive impairment of their quality of life. The results of this study allow us to know the evidence about the predictability of the context of the occurrence of TBI, as well as life changes that it will determine to the traumatized, regardless of their degree of severity. Taken together, that information can lead the development of preventive strategies aimed to control this frequent and severe public health problem.

Made available in DSpace on 2016-01-26T12:51:29Z (GMT). No. of bitstreams: 1 fernandofilipe_tese.pdf: 1172193 bytes, checksum: 8b0890c07d50bd39fe00a7a8f85c0c83 (MD5) Previous issue date: 2011-05-06 / Traumatic brain injury is the leading cause of disability, morbidity and mortality in people and has become a very important public health issue with high socioeconomic costs. Aim: To evaluate traumatic brain injuries in an urban area in respect to gender, age, occupation and schooling of the victim, the etiology of the injury, duration of hospitalization, evolution and the influence of changes in the road traffic laws on the occurrence of traumatic brain injuries. Patients and Methods: A total of 258 patients admitted to Hospital de Base as victims of brain injuries inside the urban area of São José do Rio Preto from 2005 to 2008 were analyzed. Results: Of this total, 216 were men (83.7%) with a mean age of 44.8 years (range: 4-89 years) and 42 were women (16.3%) with a mean age of 53.3 years (range: 13-96 years). Falls (34.5%) and motorcycle accidents (21.7%) were the most frequent etiologies. Mean hospitalization was 6.7 days. In general, victims were service sector workers (51.1%) and had only completed junior school (56.2%). The mortality rate among individuals who suffered traumatic brain injuries was 26.7%. A non-statistically significant drop (about 50%) in the number of traumatic brain injuries was recorded in the first half of 2008, which coincided with the introduction of tougher road traffic laws that increased punishment for drink drivers and decreased the legal blood alcoholic limit. Conclusion: Traumatic brain injuries predominantly involve men with a lower age than women. Falls are the most frequent cause in aged people, followed by motorcycle accidents in young individuals. Service sector workers are more likely to suffer traumatic brain x injuries than other manual workers. The recent change in the drink driver laws did not influence the occurrence of traumatic brain injuries. / O traumatismo crâniencefálico (TCE) é a maior causa de incapacidade, morbidade e mortalidade na população, tornando-se uma questão de saúde pública com grande importância e influência no custo socioeconômico da população. Objetivo: Analisar o TCE urbano considerando o sexo, a idade, a etiologia, o tempo de internação, a evolução, a atividade ocupacional, o grau de escolaridade e a influência da alteração do Código de Trânsito na ocorrência do TCE. Casuística e Método: Foram analisados 258 pacientes atendidos e internados no Hospital de Base vítimas de TCE dentro do perímetro urbano da cidade de São José do Rio Preto no período de 2005 a 2008. Resultados: Desse total, 216 eram do sexo masculino (83,7%) e tinham idade média de 44,8 anos (intervalo de 4 a 89 anos). Os outros 42 analisados (16,3%) eram do sexo feminino e apresentavam idade média de 53,3 anos, (intervalo de 13-96). Quanto à etiologia do trauma, observamos queda (34,5%) e acidente de moto (21,7%) como os mais freqüentes. A duração média da internação foi de 6,7 dias. A taxa de mortalidade do estudo foi de 26,7%. Os pacientes, na sua maioria, eram prestadores de serviços (51,1%) e apresentavam ensino fundamental (56,2%). Foi observada uma tendência de queda (em torno de 50%), na freqüência do TCE no primeiro semestre de 2008, sem significado estatístico, que coincidiu com o início de novas regras na Legislação de Trânsito, que tornaram as penalidades mais rigorosas e diminuíram a tolerância dos níveis de álcool no sangue dos condutores. Conclusão: O TCE apresenta-se com predomínio no sexo masculino em uma viii faixa etária inferior a do sexo feminino, sendo a queda a causa mais frequente na população idosa, seguida dos acidentes motociclísticos nos jovens. Os prestadores de serviços e com ensino fundamental são mais propensos ao TCE. As novas regras no Código de Trânsito não influenciaram a ocorrência do TCE.

Submitted by Jailda Nascimento (jmnascimento@pucsp.br) on 2016-10-05T16:13:47Z No. of bitstreams: 1 Dagliê Jorge de Freitas.pdf: 1531846 bytes, checksum: 7d1d0969c768a2b3bb2ac19ad192ddae (MD5) / Made available in DSpace on 2016-10-05T16:13:47Z (GMT). No. of bitstreams: 1 Dagliê Jorge de Freitas.pdf: 1531846 bytes, checksum: 7d1d0969c768a2b3bb2ac19ad192ddae (MD5) Previous issue date: 2016-07-04 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / The present study examined the effectiveness of social reinforcement in improving the accuracy and changing the topography of verbal self-reports about current behavior (“on-task self-report”) and past behavior (“immediate post-task self-report”) in an amnesiac outpatient. It also examined whether reinforcing accurate self-reports about current and previous behavior would result in generalization for self-reporting 30 s, 60s, 120 s and 240 s after the completion of a task. This study was conducted with a 45 year-old outpatient whose memory was impaired after suffering a cerebrovascular accident (CVA) thirteen years ago. The participant was instructed to carry out four different tasks (Reading, Assembling Lego, Looking for Shapes, Exercising) for every session (one per trial) and describe his behavior during and right after the completion of the task. After some probe sessions to determine the patient’s behavior of reporting about those four activities prior to the intervention in a multiple baseline design, a training session was introduced, in which praise was contingent to accurate self-reports about one of the four tasks. Later on, tests were undertaken to assess the acquisition and the maintenance of the trained self-reports and the effect of training on the other untrained tasks’ self-reports. There were training sessions for all tasks, except for Reading. Afterwards, tests were also undertaken in which instructions and the queries were manipulated in order to identify their effects on reporting. The results showed that, following training sessions, 1) there were fewer inaccurate immediate post-task reports; 2) the task Reading was no longer mentioned on on-task and immediate post-task reports; 3) self-edition no longer occurred; 4) the task Assembling Lego was mentioned for the first time on a inaccurate self-report; 5) for the task Exercising there were no more inaccurate on-task self-reports; 6) in post-tests following the training sessions of the reports of Looking for Shapes and Exercising, all inaccurate self-reports mentioned the task whose reports had just been trained. As for the participant’s performance after the Manipulation Tests, results indicated that 1) the topography of self-reports that mentioned one of the four tasks changed; 2) imprecise self-reports such as “I don’t know” and “I don’t remember” reemerged. In follow-up sessions, which took place 45 days after the experiment had finished, the participant emitted only correct post-task self-reports. Results indicated that, in spite of an unstable performance before and after the introduction of training sessions, social reinforcement as applied in the present study might have influenced the accuracy and the topography of verbal self-reports. Furthermore, results also indicated that both the instruction given at the beginning of every trial and the queries that requested self-reports controlled the accuracy and the topography of self-reports and that the presence of reinforcement during the tasks might render the occurrence of reports about those tasks more likely / O presente estudo buscou investigar o efeito do reforçamento social sobre a acurácia e a topografia das respostas de descrever o próprio comportamento durante a realização de uma atividade (relato intermediário) e imediatamente após a realização dessa atividade (relato final imediato) em um paciente amnésico. Buscou-se também averiguar se os eventuais efeitos desse reforçamento dos relatos correspondentes de descrição do próprio comportamento se generalizariam para os relatos que ocorressem 30 s, 60 s, 120 s e 240 s após o fim da atividade a ser relatada. A pesquisa foi realizada com um participante de 45 anos que sofreu um acidente vascular hemorrágico há treze anos e que, desde então, apresenta uma série de comportamentos descritos como déficits de memória. Foram designadas ao participante quatro tarefas distintas (Lendo, Montando Lego, Procurando Formas e Fazendo Exercício) e, a cada sessão, essas quatro atividades eram realizadas pelo participante e os relatos intermediário e final eram-lhe solicitados. Após algumas sessões de testes para verificar o comportamento de relatar essas atividades antes da intervenção em um delineamento de linha de base múltipla, ocorria uma sessão de ensino, na qual apenas uma das atividades era designada ao participante e contingentemente aos relatos intermediário e final correspondentes dessa atividade eram apresentados elogios. Em seguida, testes eram realizados para verificar a aquisição e manutenção dessas respostas ensinadas e o efeito do ensino sobre os relatos das demais atividades. Todos as atividades tiveram seus relatos ensinados, à exceção da atividade Lendo. Posteriormente, também foram realizados testes nos quais as instruções e as perguntas que solicitavam os relatos do experimento foram manipuladas a fim de identificar-lhes o efeito sobre o comportamento de relatar. A análise dos resultados indicou que, para aquelas atividades cujos relatos foram ensinados, após o ensino 1) houve proporcionalmente menos relatos finais imediatos errados; 2) a atividade Lendo deixou de ser mencionada nos relatos intermediários e finais imediatos errados de Procurando Formas e Montando Lego; 3) a presença de auto-edições nos relatos deixou de ocorrer; 4) pela primeira vez a atividade Montando Lego foi mencionada em um relato errado; 5) não houve mais relatos intermediários errados para a atividade Fazendo Exercício e 6) nos pós-testes após o ensino dos relatos de Procurando Formas e Fazendo Exercícios, todos os relatos errados mencionaram a atividade cujo relato havia sido ensinado na sessão de ensino anterior. Já para as contingências dos testes de manipulação, constatou-se que 1) a partir deles, a topografia dos relatos do participante que mencionavam as atividades especiais se alterou; 2) relatos imprecisos como “não me lembro” e “não sei” ressurgiram. Nas sessões de Follow-up imediato e Follow-up com atraso, realizadas cerca de quarenta e cinco dias após o experimento, a participante acertou todos os relatos finais. Os resultados sugerem que, apesar do desempenho instável tanto antes quantos depois do ensino, o reforçamento social tal como aplicado no experimento pode ter influenciado a acurácia e a topografia dos relatos. Além disso, os resultados indicam que as instruções dadas ao início de cada tentativa e as perguntas que solicitavam os relatos controlaram a acurácia e a topografia dos relatos e que a presença de reforçamento durante a realização de uma atividade pode tornar a ocorrência dos relatos dessa atividade mais prováveis

Submitted by Filipe dos Santos (fsantos@pucsp.br) on 2017-01-10T11:30:11Z No. of bitstreams: 1 Carla Regina Boldrini.pdf: 1316208 bytes, checksum: 2af12b29af4289c4ecbd9ffae2dd13d1 (MD5) / Made available in DSpace on 2017-01-10T11:30:11Z (GMT). No. of bitstreams: 1 Carla Regina Boldrini.pdf: 1316208 bytes, checksum: 2af12b29af4289c4ecbd9ffae2dd13d1 (MD5) Previous issue date: 2016-12-07 / Neurological disorders can let sequelae that make affected person to be unable to have independence in their daily activities, but rehabilitation can provide a partial or total recovery of lost skills. The Behavior Analysis provides useful basis for the application of procedures in a program of rehabilitation of neurological patients and has offered grants to effective interventions. This review intended to continue and expand other reviews about neurological rehabilitation, using the analysis of studies from 2011 to 2015, with single-subject design and procedures based on Behavior Analysis. This research was conducted in the databases: PsycINFO, PePSIC, Medline, LILACS, Science Direct, Wiley Online Library and SciELO BRAZIL. 20 articles were found and were defined 18 variables for analysis. The reliability index was 91%. The results indicated that there was a predominance of elderly participants diagnosed with dementia and sequelae related to cognitive difficulties and performing daily living activities. The most widely used design was a reversal and multiple baseline among participants. Few studies conducted functional analysis of behavior. Among the procedures that manipulated the background stimuli and consequences, are included: prompting, blocking and response redirection, verbal script, fading. Some studies manipulated only reinforcing consequence. Many of the procedures were classified as practice based on evidence of moderate level. Most authors reported effectiveness of the procedures applied, although few have been concerned with the implications of intervention in the daily lives of patients, failing to perform maintenance measures and social validity and to plan generalization. With the results of this review it was evident the need for future studies to deepen on the social impact of rehabilitation interventions / As patologias neurológicas podem deixar sequelas que impossibilitam a pessoa acometida de ter independência nas suas atividades cotidianas, porém um trabalho de reabilitação pode proporcionar uma recuperação parcial ou total de habilidades perdidas. A Análise do Comportamento apresenta fundamentação útil para a aplicação de procedimentos em um programa de reabilitação de pacientes neurológicos e tem oferecido subsídios para intervenções eficazes. A presente revisão pretendeu continuar e ampliar outras revisões sobre reabilitação neurológica, utilizando a análise de estudos de 2011 a 2015, com delineamento de sujeito único e com procedimentos embasados na Análise do Comportamento. A investigação foi realizada nos bancos de dados: PsycINFO, PePSIC, Medline, Lilacs, Science Direct, Wiley Online Library e SciELO Brasil. Foram encontrados vinte artigos, e definidas 18 variáveis para análise. O índice de fidedignidade foi de 91%. Os resultados indicaram que houve um predomínio de participantes idosos com diagnóstico de demência e com sequelas referentes a dificuldades cognitivas e de realização de atividades de vida diária. O delineamento mais utilizado foi de reversão e de linha de base múltipla entre participantes. Poucos artigos realizaram uma análise funcional do comportamento. Entre os procedimentos que manipularam os estímulos antecedentes e as consequências, destacaram-se: Prompting, Bloqueio e Redirecionamento de Resposta, Roteiro Verbal, Fading. Alguns estudos manipularam apenas a consequência reforçadora. Grande parte dos procedimentos foi classificada como uma prática baseada em evidência de nível moderado. A maioria dos autores relatou eficácia dos procedimentos aplicados, embora poucos tenham demonstrado preocupação com as implicações da intervenção na vida diária dos pacientes, deixando de realizar medidas de manutenção e de validade social e de planejar a generalização. Com os resultados desta revisão ficou evidente a necessidade de realizar estudos futuros que se aprofundem sobre o impacto social das intervenções de reabilitação

Ce travail de recherche porte sur la compréhension du traumatisme crânien (TC) dans les sports de glisse alpins dans l’objectif d’améliorer et d’encadrer la conception et l’évaluation des casques de ski. Il s’est décomposé en quatre étapes :Etudier les accidents de ski conduisant au TC en identifiant des typologies d’accidents de ski et de snowboard conduisant fréquemment à l’apparition de TC. A partir d’un questionnaire rempli dans 10 cabinets médicaux et 3 hôpitaux, dix scénarios d’accident ont été identifiés ainsi que les zones de la tête les plus impactées. Cette analyse est complétée par des mesures de vitesse des skieurs.Identifier les conditions d’impact de la tête en reproduisant numériquement la cinématique de ces accidents avec un modèle multicorps de skieur. Deux types d’impact ressortent de cette analyse: les impacts sur neige, majoritaires (70%) et plutôt de faibles gravités et les impacts lors de collisions, plus rares, mais souvent plus graves.Évaluer la capacité des casques à réduire le TC en combinant approches expérimentales (impact de tête instrumentée sur neige) et simulations par éléments finis (reproduction d’impacts réalistes avec un modèle d’humain virtuel). Le casque réduit efficacement le risque de TC grave lors d’impact contre un obstacle rigide, mais son efficacité reste limitée lors d’impacts contre de la neige.Explorer des pistes d’amélioration du casque. Trois solutions ont été proposées, évaluées expérimentalement et numériquement et optimisées au regard des deux impacts cibles « neige » et « obstacle ». Le prototype proposé réduit de 30% les niveaux d’accélération de la tête lors de ces impacts par rapport aux casques traditionnels. / The aim of the project was to better understand traumatic brain injury (TBI) in alpine sports in order to improve the design and the evaluation of helmets. The work was divided in four main steps: Study skiing and snowboarding accidents leading to TBI: Ten scenarios were identified with a survey available in 10 medical centers and in 3 hospitals. The frontal and occipital zones were the most impacted parts of the head. Speed measurements were performed on ski slopes to complete the accident conditions analysis.Identify head impact conditions during these accidents: We reproduced the kinematics of these accidents using a numerical model of skier and snowboarder (multibody model). We identified two types of impact: impacts against the snow are the most frequent (70%) and are associated with mild TBI whereas impacts during collision are less frequent but are more likely to induce severe TBI. Evaluate helmet effectiveness in reducing the TBI combining experimental approach (Impacts of an instrumented head against the snow) and finite element simulations (Realistic head impacts reproduced numerically using a human model). Helmets were good at reducing the risk of severe TBI during an impact against a rigid obstacle. However the effectiveness of the helmets at reducing injury risk during an impact against the snow was limited. Improve helmet design: Three solutions were studied. These solutions were proposed, evaluated experimentally and numerically and optimized regarding the two targeted impacts “snow” and “obstacle”. The prototype of the optimized helmet reduces by 30% the acceleration of the head during these impacts compared to traditional helmets.