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Biomedical subjects

D T Wade

Publications and source records attributed to D T Wade.

At least 73 records · Page 4Linked to original sources
PubMed1997

Somatosensory assessment: can seeing produce feeling?

It is conventional to assess the status of the somatosensory system in such a way that patients cannot see whether or not they are being touched: either the part tested is shielded from view or the eyes are closed. The main clinical reason for this well-established constraint on method is to control for any expectations that the visual stimulus may generate in the patient. In this study we compare the assessment of light touch with and without visual feedback in 20 well-oriented and cooperative patients after stroke, and 20 age-matched controls. The results show that in 18 of the patients, visual feedback produced only small (or no) differences in reports of sensation. Controls showed a similar result to these patients; visual feedback produced only small effects upon reported touch. In two patients, by contrast, sensation was confidently and reliably reported only when they viewed the affected limb during assessment. In one of these patients, we demonstrate that "suggestibility" is not an appropriate description of the phenomenon. The conventional clinical method of somatosensory assessment would not have elicited this informative discrepancy between feeling in the two conditions of testing in these two patients. We accordingly suggest that it is valuable to test tactile perception with and without vision when diagnosing somatosensory loss after brain damage.

Adult↗
PubMed1997

The functional anatomy of a hysterical paralysis.

The concept of a conversion disorder (such as hysterical paralysis) has always been controversial (Ron, M.A. (1996). Somatization and conversion disorders. In: B.S. Fogel, R.B. Schiffer & S.M. Rao (Eds.), Neuropsychiatry. Williams and Wilkins, Baltimore, MD). Although the diagnosis is recognised by current psychiatric taxonomies, many physicians still regard such disorders either as feigned or as failure to find the responsible organic cause for the patient's symptoms. We report a woman with left sided paralysis (and without somatosensory loss) in whom no organic disease or structural lesion could be found. By contrast, psychological trauma was associated with the onset and recurrent exacerbation of her hemiparalysis. We recorded brain activity when the patient prepared to move and tried to move her paralysed (left) leg and when she prepared to move and did move her good (right) leg. Preparing to move or moving her good leg, and also preparing to move her paralysed leg, activated motor and/or premotor areas previously described with movement preparation and execution. The attempt to move the paralysed leg failed to activate right primary motor cortex. Instead, the right orbito-frontal and right anterior cingulate cortex were significantly activated. We suggest that these two areas inhibit prefrontal (willed) effects on the right primary motor cortex when the patient tries to move her left leg.

Cerebral Cortex↗
PubMed1997

The left parietal cortex and motor attention.

The posterior parietal cortex, particularly in the right hemisphere, is crucially important for covert orienting; lesions impair the ability to disengage the focus of covert orienting attention from one potential saccade target to another (Posner, M. I. et al., Journal of Neuroscience, 1984, 4, 1863-1874). We have developed a task where precues allow subjects to covertly prepare subsequent cued hand movements, as opposed to an orienting or eye movement. We refer to this process as motor attention to distinguish it from orienting attention. Nine subjects with lesions that included the left parietal cortex and nine subjects with lesions including the right parietal cortex were compared with control subjects on the task. The left hemisphere subjects showed the same ability as controls to engage attention to a movement when they were forewarned by a valid precue. The left hemisphere subjects, however, were impaired in their ability to disengage the focus of motor attention from one movement to another when the precue was incorrect. The results support the existence of two distinct attentional systems allied to the orienting and limb motor systems. Damage to either system causes analogous problems in disengaging from one orienting/movement target to another. The left parietal cortex, particularly the supramarginal gyrus, is associated with motor attention. All the left hemisphere subjects had ideomotor apraxia and had particular problems performing sequences of movements. We suggest that the well documented left hemisphere and apraxic impairment in movement sequencing is the consequence of a difficulty in shifting the focus of motor attention from one movement in a sequence to the next.

Adult↗
PubMed1997

Measurement of post-traumatic amnesia: how reliable is it?

OBJECTIVE: To develop and test a clinical protocol for determining post-traumatic amnesia by retrospective questioning. To establish its limits and factors which influence reliability. DESIGN: Two independent assessments using the Rivermead post-traumatic amnesia protocol were undertaken by separate observers on various groups of patients at various time intervals. Analysis investigated the correlations between assessments, the percentage difference between assessments, the number of patients changing category, and the differences between these analyses in the different patient subgroups. Assessments were undertaken both in hospital and in the patients' homes. Four different patient groups were studied. These were group A: 12 inpatients with very severe head injury late after injury; Group B: 40 patients interviewed at home six months after injury; group C: 22 patients interviewed within a few weeks of injury at home; group D: 116 patients interviewed initially within a few weeks and then at six months, on both occasions at home. The Rivermead post-traumatic amnesia protocol involved clinical questioning of the patient to establish how long after injury (in hours/days/weeks) the patient regained continuous day to day memory. All periods of coma were included. Severity was categorised with standard criteria. RESULTS: Overall correlation was good (Spearman's r 0.79), but the correlation was lower for patients with post-traumatic amnesia < 24 hours and when there was a long delay between assessments. In all groups 19%-25% of patients changed categories between assessments, but only 2% changed by two categories. CONCLUSIONS: The assessment of post-traumatic amnesia with the Rivermead post-traumatic amnesia protocol is reasonably reliable. The misclassification rate however, is significant enough that some caution should be taken in individual cases. Other evidence does show post-traumatic amnesia to be valid, and it probably remains the best simple prognostic item available. In clinical practice one should avoid placing too much weight on post-traumatic amnesia alone.

Adult↗
PubMed1997

Does routine follow up after head injury help? A randomised controlled trial.

OBJECTIVE: To evaluate the Medical Disability Society's 1988 recommendation that "every patient attending hospital after a head injury should be registered and offered an outpatient follow up appointment" by determining whether offering a routine follow up service to patients presenting to hospital with a head injury of any severity affects outcome six months later. DESIGN: A randomised controlled trial design with masked assessment of outcome. SETTING: A mixed rural and urban health district with a population of about 560000. PATIENTS: 1156 consecutive patients resident in Oxfordshire aged between 16 and 65 years presenting over 13 months to accident and emergency departments or admitted to hospital and diagnosed as having a head injury of any severity, including those with other injuries. INTERVENTIONS: Patients were registered and randomised to one of two groups. Both groups continued to receive the standard service offered by the hospitals. The early follow up group were approached at 7-10 days after injury and offered additional information, advice, support, and further intervention as needed. All randomised patients were approached for follow up assessment six months after injury by independent clinicians blind to their group. MAIN OUTCOME MEASURES: Validated questionnaires were used to elicit ratings of post-concussion symptoms (the Rivermead postconcussion symptoms questionnaire), and changes in work, relationships, leisure, social, and domestic activities (the Rivermead head injury follow up questionnaire). RESULTS: The two groups were comparable at randomisation. Data was obtained at six months on 226 of 577 "control" patients and 252 of 579 "trial" patients (59% were lost to follow up). There were no significant differences overall between the trial and control groups at follow up, but subgroup analysis of the patients with moderate or severe head injuries (posttraumatic amnesia > or = one hour, or admitted to hospital), showed that those in the early intervention group had significantly fewer difficulties with everyday activities (P = 0.03). CONCLUSIONS: The results from the 41% of patients followed up do not support the recommendation of offering a routine follow up to all patients with head injury, but they do suggest that routine follow up is most likely to be beneficial to patients with moderate or severe head injuries. Some of those with less severe injuries do continue to experience difficulties and need access to services. A further trial is under way to test these conclusions.

Adaptation, Psychological↗
PubMed1997

Interventions and service need following mild and moderate head injury: the Oxford Head Injury Service.

OBJECTIVE: To describe the interventions given by the Oxford Head Injury Service (OXHIS) to patients seen after head injury, predominantly mild or moderate, over the first six months after their injuries. DESIGN: Descriptive data of the amounts of early intervention provided by OXHIS in relation to severity of head injury and the amount of service need identified at six month follow-up. SETTING: OXHIS aimed to register all patients aged 16-65 with a head injury of any severity, resident in Oxfordshire. It contacted and provided interventions for a random half of those registered at 7-10 days post-injury as part of a randomized controlled trial to investigate the effectiveness of early follow-up. At six months post-injury, independent assessment of all those registered was undertaken to evaluate outcome and identify continuing service needs. SUBJECTS: The data come from the 579 patients (of the 1156 registered), randomized to receive the new service at 7-10 days post-injury. All but eight of these received some form of service, and 252 of the randomized patients were available for interview at six months post-injury to assess their continuing service need. RESULTS: In the first five months after head injury: 240 patients received postal information alone and were not otherwise in contact with the service; 127 had telephone contact, advice and information; 93 were seen in person, assessed and given advice and information; 78 needed more help and support from the OXHIS team over the telephone; and 33 required further face-to-face contact either from OXHIS or other services. Extensive use was made of standardized leaflets but only accompanied by individualized assessment and advice. At six months 252 of the 579 patients were interviewed: 101 had no problems; 136 needed further reassurance; and 15 required further intervention. Patients with longer periods of post-traumatic amnesia (PTA) were more likely to receive a higher level of service, but the majority of patients who received the more extensive services were those with 'mild' and 'moderate' head injuries. CONCLUSIONS: Although the amount of service provided at 7-10 days post-injury increased with severity of head injury, most service was in fact given to patients with milder head injuries which were much more common. The majority of patients seen at six months post-injury needed reassurance, advice or other services, and monitoring of patients for some time after their head injuries does seem warranted. A population of 560,000 people could receive service from three whole-time equivalent (WTE) staff using these assessment and management protocols.

Adolescent↗
PubMed1997

The Barthel Index and its relationship to nursing dependency in rehabilitation.

OBJECTIVES: To investigate the clinical application of the Barthel Index as an indicator of nursing dependency in a younger disabled unit. DESIGN: A prospective study of 132 patients (mean age 49) with chronic neurological problems. SETTING: A younger disabled unit at a District General Hospital, Oxford. MAIN OUTCOME MEASURES: The Barthel Index, and total nursing hours. RESULTS: The Median Barthel Index was 7 (95% confidence interval 6-9). The mean nursing hours were 2.7 +/- 1.7 (CI 2.41-2.99). Spearman rank order correlation coefficient between the Barthel Index and nursing hours was r = -0.69 (CI -0.79 to -0.59). CONCLUSIONS: Regression analysis showed that it was possible to use the Barthel Index as an indicator of nursing dependency particularly in physical care, and that it was independent of age and diagnosis.

Activities of Daily Living↗
PubMed1996

Squints and diplopia seen after brain damage.

The aim of this study was to investigate the incidence of squint after brain damage. We performed an observational study on 239 consecutive patients admitted to a specialist neurological rehabilitation unit: 129 with stroke, 84 with head injury and 26 with other conditions. Standard orthoptic measures, including visual acuity, cover test, eye movement recording and tests of binocular function were performed. Of all the patients, 89 (37%), were found to have squints, but only 32 of these (36%) experienced double vision. Brain stem lesions causing peripheral ocular motor impairment were found in a high proportion of patients after head injury (56%). Squints were found in 27 of 95 (28%) patients with cortical strokes, many with no other signs of brain stem involvement. Left was just as likely as right hemisphere damage to be associated with squint, but right-sided lesions seemed to protect against diplopia. We conclude that squint is common after brain damage, even if the brain stem is not obviously affected, but only a minority of these patients with acquired squint suffer diplopia.

Brain Damage, Chronic↗
PubMed1996

Bedside screening for aphasia: a comparison of two methods.

A prospective study was carried out in 50 consecutive patients referred with suspected aphasia in order to compare the Frenchay Aphasia Screening Test (FAST) with the Sheffield Screening Test for Acquired Language Disorders (SST). The study included 32 men and 18 women with a mean (SEM) age 53.9 (2) years. The comprehension scores on the FAST were correlated with receptive skills on the SST r = 0.74 (P < 0.001). For expression, the correlation coefficient was r = 0.92 (P < 0.001) and the total scores of the two tests correlated closely r = 0.89 (P < 0.001). There was a positive correlation between total score on the FAST and the Short Orientation, Memory and Concentration test (SOMC) r = 0.86 (P < 0.001), and the total scores on the SST and SOMC r = 0.91 (P < 0.001). The Barthel index also correlated positively with the FAST r = 0.59 (P < 0.001) and SST r = 0.63 (P < 0.001). The study demonstrated that the two tests are simple, short and similar in their predictive value for the screening and diagnosis of aphasia. The SST was found to have additional advantages, as it does not require any special equipment or stimulus cards, and it was not affected by visual neglect.

Aphasia↗
PubMed1996

Admission after head injury: how many occur and how many are recorded?

This study attempted to determine how many patients admitted with a head injury do not have the diagnosis recorded in the medical notes, and the factors associated with this failure. This observational study took place over four weeks with a review of notes of all patients in the trauma service admission wards in a District and Teaching hospital. All patients aged 16 years to 65 years admitted to the inpatient trauma wards were included, and the frequency of diagnosis of head injury made by the investigator was compared with the frequency of a recorded diagnosis of head injury in the notes. Of 107 patients admitted 47 had had a head injury; 24 did not have the diagnosis recorded, and four of these had moderate or severe injuries. A failure to record diagnosis was more likely in the presence of other more severe injuries (21/28), and in patients with minor or trivial injuries (20/30). We conclude that head injury registers are likely to miss a significant number of patients admitted to hospital unless specific attempts are made to identify and record the diagnosis.

Adolescent↗
PubMed1996

The Rivermead head injury follow up questionnaire: a study of a new rating scale and other measures to evaluate outcome after head injury.

OBJECTIVE: To develop and evaluate a short (10 item) simple measure of outcome mainly for use with patients with mild to moderate head injuries. DESIGN: Two studies on patients at three and six months after injury, comparing different methods of administration (two raters and postal questionnaire), and comparing ratings with other assessments. SUBJECTS: Forty three patients seen three months after injury and 46 seen six months after injury; both groups had head injuries covering a range of severity from minor to severe. MAIN OUTCOME MEASURES: Differences between ratings in different groups of patients (Mann-Whitney U test); differences in ratings used different methods of administration (Wilcoxon signed rank test); and correlation between ratings from the same patient (Spearman r). RESULTS: The sum total ratings were consistent between raters and between methods (postal questionnaire v face to face interview) with no evidence of selective bias between rates or methods. Ratings on individual items were also reasonably consistent. The sum total rating varied as anticipated between groups divided by clinical judgement of recovery and patient assessment of recovery, and related as expected to the extent of post-concussion symptomatology. The 10 items included covered the most important problem areas reported by patients. CONCLUSION: The Rivermead head injury follow up questionnaire (RHFUQ) is a short, simple, adequately reliable, and valid measure of outcome, across the entire range of severity, but particularly after mild to moderate head injury.

Adolescent↗