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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
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.
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.
Competing interests: No competing interests