Rehabilitation for traumatic brain injury.
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Brain Injuries↗
Biomedical subjects
G P Prigatano
Publications and source records attributed to G P Prigatano.
Cognitive and affective improvement in brain dysfunctional patients who achieve inpatient rehabilitation goals.
OBJECTIVE: To evaluate whether improvements in specific cognitive and affective functions are associated with achieving inpatient rehabilitation goals after the acute onset of brain dysfunction. DESIGN: Retrospective analysis of data obtained in a prospective inception cohort study. STUDY SETTING: Medical center and neurological institute. SUBJECTS: Ninety-five heterogeneous brain dysfunctional patients who participated in an interdisciplinary inpatient neurorehabilitation program. Subjects were classified as having achieved their rehabilitation goals (Group 1) or not (Group 2) at time of discharge. MAIN OUTCOME MEASURE: Number of treatment goals attained. RESULTS: Although overall level of performance on the BNI Screen (BNIS) for Higher Cerebral Functions distinguished patients who later achieved their inpatient rehabilitation goals, on admission only performance on the visual spatial subtest was associated with later goal attainment. In contrast, at discharge, patients who showed greater improvement in awareness, affect, visual spatial skills, memory, and attention/concentration were likely to obtain their rehabilitation goals. This was true when the initial level of performance was taken into account. CONCLUSIONS: Measurement of overall neuropsychological status and specific visual spatial abilities at time of admission may help determine which brain dysfunctional patients will obtain inpatient rehabilitation goals. Improvement in a variety of cognitive and affective functions was associated with goal attainment. Early cognitive rehabilitation should focus on both cognitive and affective disturbances to facilitate recovery and rehabilitation outcome.
Analysis of Variance↗
Commentary: beyond statistics and research design.
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Brain Injuries↗
Initial disturbances of consciousness and resultant impaired awareness in Spanish patients with traumatic brain injury.
The purpose of this prospective, between-subjects study was to look at impaired awareness cross-culturally in patients with traumatic brain injury (TBI) and to relate impaired awareness after injury to the initial estimates of disturbed consciousness at time of injury. The study was conducted in community and inpatient and outpatient rehabilitation centers in Barcelona and Madrid. Participants were 30 persons with primarily moderate to severe TBI who could complete a written questionnaire concerning their functioning and 28 age- and gender-matched controls. A Spanish translation of the Patient Competency Rating Scale (PCRS) was administered to each participant. Relatives or significant others also completed this scale on each participant using the relative's version (PCRS-R). Difference scores, obtained by subtracting PCRS-R from PCRS-P (PCRS-P minus PCRS-R), were used as a marker of impaired awareness. Individuals with TBI were rated (by self and significant others) as being less competent than controls. Forty percent of Spanish patients with TBI who suffered severe injuries tended to overestimate their behavioral competencies. The PCRS-P minus the PCRS-R difference scores tended to correlate with admitting Glasgow Coma Scale (GCS) scores and retrospective estimates of posttraumatic amnesia (PTA). Initial disturbances of consciousness, one measure of severity of brain injury, appeared to relate to later measures of impaired self-awareness in Spanish patients with TBI. Non-brain-injured controls did not tend to report levels of competency that differed from their relatives' reports.
Adult↗
Speed of finger tapping and goal attainment after unilateral cerebral vascular accident.
OBJECTIVE: To determine (1) if speed of finger tapping is bilaterally slow after an acute unilateral cerebral vascular accident (CVA) and (2) if speed of finger tapping and grip strength are related to achieving rehabilitation goals during the first few weeks after stroke. DESIGN: Prospective inception cohort study. STUDY SETTING: Medical center and neurological institute. PARTICIPANTS: Fifty-one patients with unilateral CVAs. MAIN OUTCOME MEASURES: Documentation of goal attainment at discharge and bilateral measures of speed of finger tapping and grip strength. RESULTS: Speed of finger tapping and grip strength were often bilaterally below normal limits after an acute unilateral CVA, with the contralateral hand most affected. Speed of finger tapping, but not grip strength, in the ipsilateral hand was associated with achieving rehabilitation goals. Speed of finger tapping in the contralateral hand as well as bilateral grip strength was not related to achievement of rehabilitation goals. CONCLUSIONS: Motor findings suggest that bilateral cerebral dysfunction may be common after an acute unilateral CVA. The speed of finger movement in the hand ipsilateral to the lesion may reflect the degree to which the so-called "unaffected" cerebral hemisphere has in fact maintained its functional integrity. As such, it may be a useful behavioral marker for predicting goal attainment during early stages of neurorehabilitation.
Acute Disease↗
Prescribed versus actual length of stay and inpatient neurorehabilitation outcome for brain dysfunctional patients.
OBJECTIVE: To determine (1) whether brain dysfunctional patients have better rehabilitation outcomes if they receive prescribed length of stay (LOS) versus less than prescribed and (2) if LOS and cognitive status relate to goal attainment. DESIGN: Prospective inception cohort study. STUDY SETTING: Medical center and a neurological institute. PARTICIPANTS: One hundred six patients with acute static brain lesions. MAIN OUTCOME MEASURES: Documentation of goal attainment at discharge and maintenance of goals 6 months after discharge. All subjects also received neuropsychological tests at admission and discharge. RESULTS: Patients who received prescribed LOS achieved their rehabilitation goals at discharge more frequently than patients who received less than prescribed LOS. There was, however, no difference between groups as to maintenance of rehabilitation goals 6 months after discharge. There was no relation between number of days spent in neurorehabilitation and number of goals achieved at discharge. Cognitive status at discharge was strongly related to achieving rehabilitation goals. CONCLUSION: Although LOS may not specifically relate to goal attainment in a heterogeneous group of brain dysfunctional patients, patients who receive the prescribed LOS and who show notable improvement in cognitive status tend to achieve rehabilitation goals, compared with patients who do not.
Adult↗
Differentiating patients with higher cerebral dysfunction from patients with psychiatric or acute medical illness using the BNI Screen for Higher Cerebral Functions.
The BNI Screen for Higher Cerebral Functions (BNIS) was administered to 41 patients with known cerebral dysfunction. 22 psychiatric patients (some of whom were psychotic) without documented brain lesions, and 22 medical inpatients without neurological or psychiatric diagnoses. Patients with cerebral dysfunction scored significantly lower than the medical and psychiatric patients (p < 0.05). Utilizing the recommended cutoff score of 47, 40 of the 41 brain-dysfunctional patients were correctly classified as impaired, but only seven of the medical and five of the psychiatric patients were correctly classified. Using age-based T-scores, 36 of the 41 brain-dysfunctional patients (87.8%) were correctly classified. Specificity improved slightly, but these numbers were still low (55%), primarily because psychotic patients performed like neurological patients (100%). This study provides further empirical validation of this screening instrument in identifying patients with brain disorders.
Adult↗
A cross-cultural study on impaired self-awareness in Japanese patients with brain dysfunction.
Japanese patients with brain dysfunction (21 with severe traumatic brain injury [TBI], 21 with right, and 21 with left cerebral vascular accidents [CVA]) were asked to make behavioral ratings regarding their competencies in several areas. Relatives of patients and physical therapists who treated them also rated each patient's behavioral competency. Japanese patients with TBI overestimated their behavioral competencies compared with therapists ratings, but not relatives' ratings. Japanese patients with TBI overstimated self-care skills but not their ability to interact in socioemotional situations. Patients who had right and left CVA did not differ in their mean ratings of behavioral competency. Among all patient groups, there was no correlation between self-reported competencies and performance on a neuropsychological test. Family ratings of patients' behavioral competencies correlated with the patients' neuropsychological test performance. Post hoc analyses of patients with TBI suggest that speed of finger tapping related to an impaired self-awareness. Whereas cultural factors may influence self-reports of behavioral competency, patients across cultures with brain dysfunction seem to have reduced insight into their actual level of neuropsychological functioning.
Activities of Daily Living↗
Learning from our successes and failures: reflections and comments on "Cognitive rehabilitation: how it is and how it might be".
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Brain Injuries↗
Differential response characteristics in nonepileptic and epileptic seizure patients on a test of verbal learning and memory.
Investigators have found it difficult to separate patients with nonepileptic seizures (NES) from those with true epileptic seizures (ES) using quantitative measures of neuropsychological test performance. We examined qualitative response characteristics on the California Verbal Learning Test of 41 patients undergoing continuous video/audio-EEG monitoring in an effort to distinguish these patient groups (12 patients with left temporal [LT] foci, 11 with right temporal [RT] foci, and 18 with NES). NES patients explicitly recognized fewer target words compared with ES patients. In addition, NES patients rarely made false-positive errors, which resulted in failure to endorse a significant number of items on the recognition list. This response tendency is called a negative response bias. In contrast, LT patients endorsed a high number of items on the recognition test, which resulted in a positive response bias. RT patients demonstrated no consistent response tendency. In our sample, a negative response bias index (ie, a cutoff score < 0) showed a sensitivity of 61% and a specificity of 91%. We propose that failure to explicitly recognize words following repeated exposure may reflect aspects of psychological denial in NES patients. Response bias indices may thus help identify patients with NES and may begin to explain the psychological mechanisms underlying this complex disorder.
Adult↗
Digit Memory Test: unequivocal cerebral dysfunction and suspected malingering.
The Digit Memory Test (DMT) (Hiscock & Hiscock, 1989), a forced-choice test for detecting malingering, was administered to 27 patients with unequivocal cerebral dysfunction, 5 patients with postconcussional syndrome, 6 suspected malingerers and 10 normal controls. Results indicate that, even in patients with severe, but static cerebral dysfunction and unequivocal memory disorder, DMT performance is between 95% to 100% correct. By contrast, the 6 patients in whom malingering was seriously considered performed at a level much below the other three groups (74% correct) but not significantly below chance. The DMT may be helpful in evaluating patients suspected of malingering even when they do not score significantly below chance.
Adult↗
Uses and abuses of neuropsychological testing in behavioral neurology.
This article provides a brief historical review of how psychological tests have been used to examine patients with brain dysfunction and summarizes the strengths and weaknesses of present-day neuropsychological testing procedures. Common uses and abuses of neuropsychological testing are listed with a few clinical examples.
Behavioral Sciences↗
Personality disturbances associated with traumatic brain injury.
Personality disturbances associated with traumatic brain injury are reviewed. The varied structural pathology of the brain in this patient group makes it difficult to specify how different brain lesions may result in specific emotional and motivational disturbances. However, an attempt to clarify terms and review empirical findings is made. Longitudinal prospective studies that utilize appropriate control groups are needed. Future research may especially benefit by considering the long-term effects of early agitation following traumatic brain injury as well as the problem of aspontaneity and impairment of self-awareness.
Adult↗
Impaired awareness of behavioral limitations after traumatic brain injury.
Sixty-four traumatically brain injured patients were divided into three groups. Patients in Group I overestimated their behavioral competencies. Patients in Group II showed behavioral ratings similar to relatives' reports concerning behavioral competencies. Patients in Group III underestimated their behavioral competencies. Group I patients had greater evidence of bilateral and multiple-site lesions than group II and III patients. Speed of left-hand finger tapping was also worse in Group I than groups II and III, but other standard neuropsychologic test findings failed to separate the groups. Specific brain lesion sites were not related to group membership. Impaired awareness of behavioral limitations after traumatic brain injury may be related to neuropsychologic changes not measured by standard tests. Bilateral impairment of heteromodal cortex may be important to this phenomenon when it exists several months or years postinjury.
Adult↗
Work, love, and play after brain injury.
Human self-awareness is not easily reducible to known principles of neurochemistry, neurophysiology, or neuropsychology. The author encourages a broader, less restrictive exploration of the nature of self-awareness as it relates to brain-injured patients. He elucidates the role of symbols in neuropsychological rehabilitation and suggests that work, love, and play are the primary symbols of normality that can reconcile brain-injured patients to their neurological condition.
Awareness↗
Progressive neuropsychologic impairment and hypoxemia. Relationship in chronic obstructive pulmonary disease.
In previous work we showed that patients with chronic obstructive pulmonary disease (COPD) suffered decrements in neuropsychologic functioning suggestive of organic mental disturbance. This study combined data from two multicenter clinical trials to explore the nature and possible determinants of such neuropsychologic change. Three groups of patients with COPD whose hypoxemia was mild (N = 86), moderate (N = 155), or severe (N = 61) were compared with age- and education-matched nonpatients (N = 99). The rate of neuropsychologic deficit rose from 27% in mild hypoxemia to 61% in severe hypoxemia. Various neuropsychologic abilities declined at different rates, suggesting differential vulnerability of neuropsychologic functions to progress of COPD. Multivariate analyses revealed a consistent significant relationship between degree of hypoxemia and neuropsychologic impairment, but the amount of shared variance was small (7%). Increasing age and lower education were also associated with impairment.
Adult↗
Recovery and cognitive retraining after craniocerebral trauma.
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Adult↗
Neuropsychology of aging.
In normal aging, decline in some, but not in all aspects of intelligence and memory are seen. The general health status of the individuals may exacerbate the normal aging process. Moreover, the emotional-motivational characteristics of the elderly seem to play a predominant role in over-all quality of life and psychosocial adjustment to the aging process.
Affect↗