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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 2  |  Issue : 4  |  Page : 151-158

A Survey on normal-Pressure hydrocephalus in Shanghai community health-care Professionals in Yangpu Community Training Program for Rehabilitation Medicine


1 Neurorehabilitation Centre, The First Rehabilitation Hospital of Shanghai, Shanghai, China
2 Center for Translational Neurodegeneration and Regenerative Therapy, Shanghai Tenth People's Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
3 Stroke Rehabilitation, MossRehab, Elkins Park, PA, USA

Date of Submission20-Apr-2019
Date of Decision12-Jun-2019
Date of Acceptance28-Jun-2019
Date of Web Publication22-Oct-2019

Correspondence Address:
Prof. Zhen Chen
Neurorehabilitation Centre, The First Rehabilitation Hospital of Shanghai, Shanghai
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jisprm.jisprm_57_19

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  Abstract 


Objectives: Gait ataxia, incontinence, and cognitive impairment are three typical symptoms of normal pressure hydrocephalus (NPH), however, similarity to other diseases' presentation, the diagnosis of NPH can be frequently missed. NPH-related education program to healthcare professionals appears very well needed and could be a promising way to improve its early diagnosis and treatment, but the actual effect of training programs is unknown. Therefore, we launched the Yangpu Community Training Program and conducted a survey to investigate the knowledge and awareness of NPH among rehabilitation professionals and the effectiveness of our training program. Methods: We conducted a well designed survey among the participants before and after education of NPH and analyzed the responses of returned questionnaires. We compared the percent of respondents who never learned about NPH before and after training, and analyzed potential factors (year of graduation and professions) that might affect NPH education. We also examined the source of the acquired NPH knowledge and the percentage of respondents who demonstrated their increased knowledge of this disease. Results: Eighty-two and eighty-six questionnaires were returned before and after training, respectively. Based on data from the returned questionnaires, more than 80% of participants in the training program are rehabilitation therapists (physical, occupational and speech therapists), 15% are physicians, and 2% are nurses. Before participating in the training program, more than two fifths (41.46%) surveyed healthcare professionals had never learned about NPH, however this number dropped to 4.76% after training, Sixty percent participants indicated that they learned about NPH from the provided training programs. Conclusion: Our results demonstrate that NPH knowledge is lacking among healthcare professionals and that training programs are effective in NPH education. We expect that increased knowledge of this disease would result in improvement on early detection of this condition and appropriate intervention implemented to reduce the patients, family and health care burden in the future.

Keywords: Education, normal-pressure hydrocephalus, rehabilitation, survey


How to cite this article:
Chen Z, Wang Y, Cao N, Chen C, Wang Y, Ru Y. A Survey on normal-Pressure hydrocephalus in Shanghai community health-care Professionals in Yangpu Community Training Program for Rehabilitation Medicine. J Int Soc Phys Rehabil Med 2019;2:151-8

How to cite this URL:
Chen Z, Wang Y, Cao N, Chen C, Wang Y, Ru Y. A Survey on normal-Pressure hydrocephalus in Shanghai community health-care Professionals in Yangpu Community Training Program for Rehabilitation Medicine. J Int Soc Phys Rehabil Med [serial online] 2019 [cited 2020 Feb 19];2:151-8. Available from: http://www.jisprm.org/text.asp?2019/2/4/151/269738




  Introduction Top


Hydrocephalus is broadly defined as an excess of cerebrospinal fluid (CSF) in the brain, usually in the ventricular system. Although hydrocephalus patients can present multiple symptoms such as nausea, headache, vomiting, and a gradual decline of intellectual and motor activity, the most typical clinical symptoms are gait ataxia, cognitive disturbance, and urinary incontinence. Symptoms caused by hydrocephalus are potentially reversible through the diversion of CSF using a ventriculoperitoneal, ventriculoatrial, or lumboperitoneal shunt, which can be successfully provided given a correct diagnosis.[1]

Hydrocephalus is divided into two categories. The first type is secondary hydrocephalus, which is often the result of craniocerebral trauma, subarachnoid hemorrhage, intracranial infection, brain tumor, and other diseases with clear pathogenesis. The second type is idiopathic hydrocephalus, which has no clear cause in the clinic and occurs mostly in the elderly.

With the rapid development in medicine and improved economics, the aging of the world population has become evident. With the aging of the population, the prevalence of dementia has increased.[2] Most dementias do not have any effective treatment and are almost irreversible. However, it should not be overlooked that dementia caused by hydrocephalus is reversible, especially in the early stages of the disease.[3] Normal-pressure hydrocephalus (NPH) was first described in 1965 by Dr. Hakim and Dr. Adams[4] NPH may develop after trauma or other secondary reasons, but majority of cases present idiopathically. The prevalence of probable idiopathic NPH (iNPH) was 0.2% (2 out of 834) in those aged 70–79 years and 5.9% (24 out of 404) in those aged 80 years and older, with no difference between men and women. Unfortunately, only two out of these 26 iNPH patients had been diagnosed and treated as iNPH in Sweden between 1986 and 2000.[5] Secondary NPH caused by craniocerebral injury or cerebrovascular diseases such as aneurysmal subarachnoid hemorrhage and ventricular hemorrhage.[6],[7] can also lead to disturbance of consciousness, dementia, abnormal gait, and urinary incontinence. Early active and effective shunt surgery can promote the recovery of patients with disorders of consciousness, improve cognitive and walking functions, and change urinary abnormalities, thereby fundamentally improving the symptoms and quality of life of patients.

There are three categories of hydrocephalus according to the pressure of lumbar puncture, namely, high pressure (CSF drainage pressure using a lumbar catheter >180 mmH2O), normal pressure (80–180 mmH2O), and low pressure (<80 mmH2O). According to the time of onset, hydrocephalus can be divided into acute (0–3 days after onset), subacute (4–14 days after onset), and chronic hydrocephalus (more than 14 days after onset). Few reports are available on the prevalence or incidence of NPH. One report indicated that the incidence of hydrocephalus was at least 5.5/100,000 in the Norwegian population.[8] Based on the United States Hydrocephalus Association, it is estimated that more than 700,000 Americans have NPH, but less than 20% have received appropriate diagnosis.

In Shanghai, China, the average life expectancy of people is 80.98 (male) and 85.85 (female) according to the 2017 Annual Report of Shanghai Municipal Commission of Health and Family Planning. Moreover, it is difficult to distinguish NPH-related dementia from Alzheimer's disease, dementia with Lewy body, brain atrophy, or vascular dementia.[9] Hence, early detection and diagnosis of decompression caused by NPH is essential.

In addition, iNPH with gait, balance disorder, and cognitive impairment is an important cause of falls in the elderly and a frequent admission to hospital emergency departments. Patients who present to the emergency department of neurosurgery often suffer from “inadvertent fall and head trauma,” and the diagnosis is often “head trauma.” Those patients' routine examination of head computed tomography showed “aging brain changes, brain atrophy, multiple luminal infarctions.”, therefore, there is no need for further treatment, so routine diagnosis and treatment may end here. However, if you further inquire about the patient's history, it is often found that repeated falls, dementia, urinary incontinence, etc., were present, and patients may have visited emergency department multiple times, but there is no clear diagnosis of the disease and an effective treatment offered. Frequent falls cause great stress and negative effects on the psychology and physiology of patients, thus seriously affecting the patients' and their caregivers' quality of life. Over time, cognitive impairment is aggravated which increases the probability of falling, forming a vicious circle, which later develops into inactivity, severe dementia, and urinary incontinence.[10]

Lack of knowledge on NPH can lead to frequent misdiagnosis which will contribute to mistreat this condition. According to a survey on 284 physicians worldwide, around 7% were graduated by 1996–2005 and never learned of NPH, and this percentage increased among the older groups and reached 49% among 1935–1965 graduates.[11] These results indicate that NPH education needs to be strengthened globally. In China, there is no report on the knowledge of health-care professionals about NPH. For the purpose of education, we launched the Yangpu Community Training Program for Rehabilitation (YCTPR), in which NPH diagnosis and treatment education was introduced to community health-care workers in Yangpu District, Shanghai, China. A survey was conducted to investigate training participants' knowledge on NPH. Not surprisingly, our results demonstrated that NPH knowledge is lacking among health-care professionals who participated in the program and that training programs are an effective way in NPH education.


  Methods Top


This study was reviewed and approved by the Institutional Review Board of theFirst Rehabilitation Hospital of Shanghai. The questionnaire for our survey was designed based on the one used by Conn and Lobo.[11] The simple one-page questionnaire can be completed within 3 min. Questionnaires were given to the participants before [questionnaire 1] and after [questionnaire 2] YCTPR training held on December 16, 2018.

The YCTPR is a series of training programs on rehabilitation medicine which is led by Yangpu District Health Planning commission. Every year, the Yangpu District Health Planning Commission conducts academic and professional training for rehabilitation professionals of hospitals at all levels in the district, focusing on rehabilitation-related clinical treatment, rehabilitation training, and nursing care. These training programs focus on the common etiology, clinical manifestations, diagnostic methods, and criteria of NPH.

Questionnaire 1 contains five questions in total [Questionnaire 1]. The purpose of questionnaire 1 is to assess the current level of knowledge and understanding of NPH among the training participants. Questionnaire 2 contains ten questions in total. The first five questions of questionnaire 2 are the same as those of questionnaire 1. The last four questions of questionnaire 2 are test questions on NPH-related knowledge. All the four are multiple-choice questions where at least one option is correct. The purpose of questionnaire 2 is to investigate how well participants learned about NPH from the training programs, which implies whether our trainings are effective for NPH education. All questions were presented in Chinese. Respondents to questionnaire 1 and questionnaire 2 were participants of the YCTPR on December 16, 2018. These participants are mainly rehabilitation physical therapists, and the rest are physicians and nurses from the community health-care facilities of Yangpu District, Shanghai, China. The participants were encouraged, but not required to fill out and return the questionnaire. Questionnaires with more than 50% of questions answered by the respondents were included in the analysis. All the questionnaires were collected anonymously unless the participant intended to write down his or her name. Because of the anonymity, an informed consent is not required according to the ethics committee of the institutional review board.

Participants' choices were recorded in Excel spreadsheets. Chi-square test or Fisher's exact test was used to compare participants' learning of NPH between different professions or year of graduation. Analysis was made using SAS. The number and percentage of participants' choices before and after training were compared. The number and percentage of participants who had answered each test question correctly after training were also presented.


  Results Top


Survey participants

Eighty-two and eighty-six questionnaires were returned before and after training, respectively. Based on information from the 82 returned questionnaires, the majority (68, 82.93%) of the respondents are rehabilitation therapists, about one-tenths (12, 14.63%) are physicians, and 2 (2.44%) are nurses [Table 1]. In rehabilitation training, therapists have more contact time with patients and may detect abnormal clinical manifestations of patients earlier. Therefore, this study strengthens the training of therapists. Among all respondents to questionnaire 1, 76 wrote down the year of their graduation from medical/nursing school. Fifty-four (71.05%) respondents were graduated in 2013–2018, eleven (14.47%) in 2007–2012, 3 (3.95%) in 2001–2006, and 8 (10.53%) before 2000 [Table 1]. The participants who returned questionnaire 2 constituted 73 (84.88%) rehabilitation therapists, 10 (11.63%) physicians, and three (3.49%) nurses [Table 2]. Among the 86 respondents of questionnaire 2, 82 wrote down the year of graduation. Fifty-eight (70.73%) respondents were graduated in 2013–2018, 50 (18.29%) in 2007–2012, three (3.66%) in 2001–2006, and six (7.32%) before 2000 [Table 2]. Notwithstanding close similarity, it can be said that respondents to questionnaire 1 and questionnaire 2 are not exactly the same group of people. The slight difference is likely due to the voluntary nature of participation.
Table 1: Information of the participants surveyed before training

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Table 2: Information of the participants surveyed after training

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A considerable percentage of the surveyed health-care professionals never learned about normal-pressure hydrocephalus before the Yangpu Community Training Program for Rehabilitation

Based on returned questionnaire 1, 34 out of the 82 (41.46%) community health-care professionals had never learned about NPH before participating in the provided training program. For the rest of respondents, 17 (20.73%) learned about NPH during medical or nursing school, one (1.22%) learned about NPH during residency, none learned NPH during fellowship, and 30 (36.59%) learned about NPH from other training programs. Among the different professions of the respondents, eight out of 12 physicians (66.67%) never learned about NPH, two (16.67%) learned about NPH during medical school, and the other two (16.67%) from training programs; 26 out of 68 (38.24%) rehabilitation therapists never learned about NPH, 26 (38.24%) learned about NPH from training programs, 15 (22.06%) during medical school, and one (1.47%) during residency; the two respondent nurses learned about NPH from the provided training program [Table 3]. Fisher's exact test showed that there was no statistically significant difference in participants' learning of NPH between professions. These results demonstrate that NPH-related knowledge is lacking among health-care professionals in Yangpu District, Shanghai, regardless of their profession. Regarding the investigation of whether participants' year of graduation had influenced their knowledge about NPH, we found that 19/54 (35.19%) of 2013–2018 graduates, 6/11 (54.55%) of 2007–2012 graduates, and 3/3 (100%) of 2001–2006 graduates had never learned about NPH [Table 4]. No significant difference in participants' learning of NPH across year of graduation was found (Fisher's exact test), indicating a lack of knowledge about NPH in the participants regardless of their year of graduation.
Table 3: Stages of career at which the surveyed participants (by profession) learned about normal-pressure hydrocephalus before training

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Table 4: Stages of career at which the surveyed participants (by year of graduation) learned about normal-pressure hydrocephalus before training

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Among 73 participants who responded to the question “how many NPH patients have you seen in the past 5 years,” the majority (53/73, 72.60%) answered 0. Among 70 participants who responded to the question “how many patients have you referred for NPH diagnosis or treatment in the past 5 years,” a substantial majority (66/70, 94.29%) answered 0 [Table 1]. Again, these results indicate that NPH diagnosis and treatment are underdiagnosed and likely to be neglected among community health-care professionals.

The Yangpu Community Training Program for Rehabilitation effectively implemented a normal-pressure hydrocephalus education among communiy health-care professionals

After training, only four out of the 84 (4.76%) respondents indicated that they had never learned about NPH, whereas 62 out of the 84 (73.81%) respondents responded that they had learned about NPH from the training program provided [Table 2]. All the respondent physicians indicated that they had learned about NPH, in which nine out of the ten (90%) learned about NPH from the provided training program; yet four out of 71 (5.63%) participating therapists chose “never learned about NPH” after the YCTPR, whereas 50 (70.42%) therapists responded that they had learned about NPH from the training programs; all the three respondent nurses learned about NPH from the training programs [Table 5]. The four respondents who chose “never learned about NPH” after training were all graduated during 2013–2018 [Table 6]. Compared with what happened before the YCTPR, it can be reported that the percentage of respondents who had never learned about NPH largely decreased, and the majority of respondents had learned about NPH from training programs. For the question “how did you learn about NPH” of questionnaire 2 where multiple options were provided, “learned about NPH from the provided training programs” was selected sixty times (63.83%) by respondents, making “training programs” the dominant source of NPH knowledge compared with “from textbook” five times (5.32%), “medical journals” four times (4.26%), “lecture” 17 times (18.09%), “grand rounds” seven times (7.45%), and “others” once [1.06%, [Table 7]. These results indicate that the YCTPR has effectively helped NPH education among community health-care workers in Yangpu District, Shanghai, China.
Table 5: Stages of career at which the surveyed participants (by profession) learned about normal-pressure hydrocephalus after training

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Table 6: Stages of career at which the surveyed participants (by year of graduation) learned about normal-pressure hydrocephalus after training

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Table 7: Source of information by which the participants learned of normal-pressure hydrocephalus after training

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Furthermore, 81 participants returned answers to test questions in questionnaire 2 after training. Sixty-eight (83.95%) respondents had the correct answer to the “common symptoms of hydrocephalus” and 78 (97.5%) to “pressure range of NPH.” However, unexpectedly, only 10 (12.35%) had correct answer to “hydrocephalus can be secondary to which common diseases” and 41 (51.62%) to “common diagnostic strategies for hydrocephalus” [Table 8], which may be explained by the fact that most of the trainees are therapists who pay more attention to clinical manifestations and are not familiar with clinical diseases and disease diagnostic methods. Together, these results indicate that the YCTPR is an effective program and has helped NPH education among community health-care workers in Yangpu District, Shanghai, although one training session seems inadequate to convey the essential NPH-related knowledge to all participants.
Table 8: Test questions answered by the participants after training

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  Discussion Top


In this study, we surveyed rehabilitation professionals' knowledge and understanding of NPH. More than 80% of the survey participants are rehabilitation therapists, around 10% are physicians, and the rest are nurses. Before participating in the YCTPR, around 41.46% of the surveyed rehabilitation professionals had never learned about NPH. After training, this number dropped to 4.76%. Around 60% of the respondents indicated that they had learned about NPH from the provided training program. In summary, our results demonstrate that NPH knowledge is lacking among rehabilitation professionals and that training programs are an effective NPH education method.

It appears that neither different professions of participants (physicians, therapists, or nurses) nor the time period of their graduation has any significant effect on participants' mastering of NPH-related knowledge before, or after, the training. This suggests that the current lack of knowledge on NPH applies to rehabilitation professionals across professions and graduates of different time periods, indicating the necessity of NPH training programs for all rehabilitation professionals regardless of their time of graduation or their educational background. Encouragingly, the percentage of participants who responded “never learned about NPH” largely dropped after the YCTPR training, regardless of their professions or year of graduation from medical/nursing school, suggesting that training is effective on NPH education among all participants. One thing to note is that only 10 (12.35%) participants correctly answered to “hydrocephalus can be secondary to which common diseases” and 41 (51.62%) to “common diagnostic strategies for hydrocephalus” even after training, far from the desired percentage. This suggests that one-time training is not enough and training series on related knowledge may be required.

The diagnosis of NPH can be frequently missed because normal intracranial pressure and the typical symptoms of NPH are similar to that of other diseases such as Parkinson's disease and Alzheimer's disease. In addition, this disease may present in a surprisingly large number of ways. In this case, not only improving the awareness among professionals, but also education to patients and families is equally valuable.

The typical symptoms of NPH, such as gait ataxia, incontinence, and dementia, can be ameliorated or even reversed if timely diagnosed and proper treatment is implemented.[12],[13] However, unfortunately, it seems that NPH diagnosis and treatment has been neglected or at least underemphasized.[10] The underemphasis of NPH is not only reflected by our study but also supported by the Conn and Lobo's[11] survey of 2008. Although the awareness of NPH has improved in more recent graduates based on Conn and Lobo's[11] survey, we did not see the trend in our survey even with improved availability of diagnostic and treatment measures in China for the past years. Therefore, an effective training program is undoubtedly well needed, especially for rehabilitation clinicians.

Patients with severe brain injury, aneurysmal subarachnoid hemorrhage, intraventricular hemorrhage, brain tumor, etc., will frequently be transferred to inpatient rehabilitation centers for treatment due to dysfunction of consciousness, cognition, movement, speech, urology, etc., after their primary diseases are stable; therefore, physiatrists and therapists should also promptly discover and diagnose the complications that may occur during rehabilitation.

In addition, as the clinical situation gradually stabilizes and improves, patients will be transferred to the community for long-term rehabilitation. Therefore, most patients with dementia, gait abnormalities, and urinary incontinence after chronic hydrocephalus are treated in community hospitals for postrehabilitation treatment. Therefore, doctors and therapists in community hospitals are essential to recognize and improve their awareness of NPH.

Limitation

This study focused only on community doctors and therapists. We did not further investigate the knowledge of hydrocephalus by other disciplines such as neurology, neurosurgery, emergency department, rehabilitation, urology, and community for the understanding of hydrocephalus, so future research in this area is necessary. Another limitation is lack of survey on knowledge retention. We did only pre-post survey after training, but did not know how long the participants can remember this information, for example, how much they still know at 3 months and 6 months after training.


  Conclusion Top


In order to investigate the current level of knowledge and understanding of NPH among training participants and how well participants learned about NPH from the training programs, we conducted this survey before and after training. Our results showed that a considerable percentage of participants (41.46%) had never learned about NPH, demonstrating the lack of NPH education among the surveyed community health-care professionals. Encouragingly, the percentage of respondents who chose “never learned about NPH” decreased to 4.76% after training, and “training programs” were selected as the dominant source of NPH information (63.83%) by the respondents, compared with other sources including textbooks, medical journals, lectures, and grand rounds. Together, our results indicate that the YCTPR is an effective program and has helped NPH education among community health-care workers in Yangpu District, Shanghai, although one training course seems insufficient to achieve NPH-related knowledge for all participants.

Acknowledgment

The authors thank Dr. Alberto Esquenazi at the MossRehab/Einstein Healthcare Network, USA, for his valuable guidance and suggestion on the study.

Financial support and sponsorship

We acknowledge the funding from Shanghai Municipal health commission (Grant NO. 201740198) and Yangpu District Municipal health commission of Shanghai (Grant No. YP16ZA09, Excellent Leading Physician).

Conflicts of interest

There are no conflicts of interest.


  Questionnaires Top


Questionnaire 1

Name:

1. I am a:

A. Physician B. Rehabilitation therapist C. Nurse

2. I graduated from medical/nursing school in the year:____

3. I learned about normal.pressure hydrocephalus at the time of:

A. Medical school B. Residency C. Fellowship D. Training programs E. Never learned

4. I have seen about________ patients with NPH in the past 5 years

(number)

5. I have referred about________ patients for the diagnosis or treatment of NPH in the past 5 years.

(number)

Date:

Questionnaire 2

Name:

1. I am a:

A. Physician B. Rehabilitation therapist C. Nurse

2. I graduated from medical/nursing school in the year____

3. I first learned about normal.pressure hydrocephalus at the time of:

A. Medical school B. Residency C. Fellowship D. Training programs E. Never learned

4. I have seen about________ patients with NPH in the past 5 years

(number)

5. I have referred about________ patients for the diagnosis or treatment of NPH in the past 5 years.

(number)

6. How did you learn about NPH? (one or more options can be selected)

A. Textbooks B. Journals C. Lectures D. Grand rounds E. Training programs F. other: ______

NPH knowledge test questions (at least one option is correct):

7. Which are the common symptoms of hydrocephalus?

A. Cognitive decline B. Impaired gait C. Incontinence D. None of the above

8. What is the pressure range of NPH?

A. <80 mmHg B. 80.180 mmHg C. >180 mmHg D. None of the above

9. Usually, hydrocephalus can be secondary to which common diseases:

A. Cerebral hemorrhage B. Cerebral infarction C. Brain tumor D. None of the above

10. Common diagnostic strategies for hydrocephalus include:

A. Brain images B. TAPE test C. Clinical symptoms D. None of the above

Date



 
  References Top

1.
Peterson KA, Savulich G, Jackson D, Killikelly C, Pickard JD, Sahakian BJ. The effect of shunt surgery on neuropsychological performance in normal pressure hydrocephalus: A systematic review and meta-analysis. J Neurol 2016;263:1669-77.  Back to cited text no. 1
    
2.
Prince M, Ali GC, Guerchet M, Prina AM, Albanese E, Wu YT. Recent global trends in the prevalence and incidence of dementia, and survival with dementia. Alzheimers Res Ther 2016;8:23.  Back to cited text no. 2
    
3.
Brean A, Eide PK. Prevalence of probable idiopathic normal pressure hydrocephalus in a Norwegian population. Acta Neurol Scand 2008;118:48-53.  Back to cited text no. 3
    
4.
Hakim S, Adams RD. The special clinical problem of symptomatic hydrocephalus with normal cerebrospinal fluid pressure. Observations on cerebrospinal fluid hydrodynamics. J Neurol Sci 1965;2:307-27.  Back to cited text no. 4
    
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Jaraj D, Rabiei K, Marlow T, Jensen C, Skoog I, Wikkelsø C. Prevalence of idiopathic normal-pressure hydrocephalus. Neurology 2014;82:1449-54.  Back to cited text no. 5
    
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Chen Z, Song W, Du J, Li G, Yang Y, Ling F. Rehabilitation of patients with chronic normal-pressure hydrocephalus after aneurysmal subarachnoid hemorrhage benefits from ventriculoperitoneal shunt. Top Stroke Rehabil 2009;(Sept-Oct): 330-8.  Back to cited text no. 6
    
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Chen Z, Yang Y, Chen G, Wang M, Song W. Impact of ventriculoperitoneal shunting on chronic normal pressure hydrocephalus in consciousness rehabilitation. J Rehabil Med 2014;46:876-81.  Back to cited text no. 7
    
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Brean A, Fredø HL, Sollid S, Müller T, Sundstrøm T, Eide PK. Five-year incidence of surgery for idiopathic normal pressure hydrocephalus in Norway. Acta Neurol Scand 2009;120:314-6.  Back to cited text no. 8
    
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Molde K, Söderström L, Laurell K. Parkinsonian symptoms in normal pressure hydrocephalus: A population-based study. J Neurol 2017;264:2141-8.  Back to cited text no. 9
    
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Picascia M, Zangaglia R, Bernini S, Minafra B, Sinforiani E, Pacchetti C. A review of cognitive impairment and differential diagnosis in idiopathic normal pressure hydrocephalus. Funct Neurol 2015;30:217-28.  Back to cited text no. 10
    
11.
Conn HO, Lobo FM. What do physicians know about normal pressure hydrocephalus and when did they know it? A survey of 284 physicians. Yale J Biol Med 2008;81:19-29.  Back to cited text no. 11
    
12.
Agerskov S, Hellström P, Andrén K, Kollén L, Wikkelsö C, Tullberg M. The phenotype of idiopathic normal pressure hydrocephalus – A single center study of 429 patients. J Neurol Sci 2018;391:54-60.  Back to cited text no. 12
    
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Klinge P, Hellström P, Tans J, Wikkelsø C; European iNPH Multicentre Study Group. One-year outcome in the European multicentre study on iNPH. Acta Neurol Scand 2012;126:145-53.  Back to cited text no. 13
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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