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NEWS: Zosia Kmietowicz New technique helps to assess vegetative state BMJ 2000; 321: 196 [Full text]

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Leg Crossing In Patients In A Vegetative State: A Sign Of Returning Awareness

Bruno Zanotti   (30 November 2000)

Leg Crossing In Patients In A Vegetative State: A Sign Of Returning Awareness 30 November 2000
Bruno Zanotti, M.D. Neurosurgery University of Verona, Italy Send response to journal: Re: Leg Crossing In Patients In A Vegetative State: A Sign Of Returning Awareness	Editor - Zosia Kmietowicz reported a new technique: the Sensory Modality Assessment Rehabilitation Technique (SMART) which helps to assess patients in a vegetative state.1 Vegetative state (VS) is a clinical condition of complete unawareness of self and environment accompanied by sleep-wake cycles with full or partial preservation of the autonomic functions of the hypothalamus and brain stem.2 The condition may be transient or persistent and some patients may start to improve after different periods.3, 4 It is vital to establish the patient's potential recovery from VS. The SMART technique provides a structured sensory program which evaluates the five senses and movement, communication and wakefulness. It also monitors the patient's ability to demonstrate a consistent, meaningful and functional response to stimulation. We think this technique could be of benefit associated with and/or preceded by clinical observation of lower limb position. In fact, we observed in patients who will emerge from VS, unlike those who will not recover, a typical reduction in posture, gradually replaced by a more natural position in which spontaneous leg crossing, one ankle over the other. This readily detectable sign indicates that awareness is about to return. It is a clear-cut indication among the slow subtle changes which occur on the way to regained awareness which can only be disclosed or established after repeated assessments. Leg crossing in VS patients with hemiparesis is obviously achieved by the non paralysed limb. Leg crossing is a typical posture in normal subjects and the tendency to cross legs has genetic implications.5 It is presumably controlled by the brain even though the underlying mechanism remains unsettled.5 The appearance of this posture in VS could be correlated with a gradual reintegration of cortical functions. Spontaneous leg crossing in a subject in a vegetative state could be a warning signal, to be confirmed by SMART assessment, which assesses, at the earliest opportunity, whether the patient has emerged from the vegetative state. Bruno Zanotti, M.D. Angela Verlicchi, M.D. Department of Neurosurgery, University of Verona (Director Albino Bricolo), Department of Neurosurgery, "S.Maria della Misericordia" Hospital, Udine, Italy newmagaz@tin.it 1. Kmietowicz Z. New technique helps to assess vegetative state. BMJ 2000;321:196. (22 July.) 2. The Multi-Society Task Force on PSV. Medical aspects of the persistent vegetative state (first of two parts). N Engl J Med 1994;330:1499-508. 3. Verlicchi A, Zanotti B. Il coma & Co. Trento, Italy: new Magazine Edition, 1999. 4. Bricolo A. Prolonged post-traumatic coma. In: Vinked PJ, Bruyn GW, eds. Handbook of Clinical Neurology. Injures of the brain and skull (vol 24, part II). New York: American Elsevier Publishing Company, 1976:699-755. 5. Reiss M. Leg-crossing: incidence and inheritance. Neuropsychologia 1994;32:747-50.