Evaluation of differentiated neurotherapy programs for a patient after severe TBI and long term coma using event-related potentials.

BACKGROUND: This article examines the effectiveness of differentiated rehabilitation programs for a patient with frontal syndrome after severe TBI and long-term coma. We hypothesized that there would be a small response to relative beta training, and a good response to rTMS, applied to regulate the dynamics of brain function. CASE REPORT: M. L-S, age 26, suffered from anosognosia, executive dysfunction, and behavioral changes, after a skiing accident and prolonged coma, rendering him unable to function independently in many situations of everyday life. Only slight progress was made after traditional rehabilitation. The patient took part in 20 sessions of relative beta training (program A) and later in 20 sessions of rTMS (program B); both programs were combined with behavioral training. We used standardized neuropsychological testing, as well as ERPs before the experiment, after the completion of program A, and again after the completion of program B. As hypothesized, patient M.L-S showed small improvements in executive dysfunction and behavioral disorders after the conclusion of program A, and major improvement after program B. Similarly, in physiological changes the patient showed small improvement after relative beta training and a significant improvement of the P300 NOGO component after the rTMS program. CONCLUSIONS: The rTMS program produced larger physiological and behavioral changes than did relative beta training. A combination of different neurotherapeutical approaches (such as neurofeedback, rTMS, tDCS) can be suggested for similar severe cases of TBI. ERPs can be used to assess functional brain changes induced by neurotherapeutical programs.

Differential diagnosis of behavioral variant of fronto-temporal dementia (bvFTD).

BACKGROUND: The aim of the paper is the differential diagnosis of various types of Fronto-Temporal Dementia (FTD), with the focus on its behavioural variant (bvFTD). MATERIAL/METHOD: Screening was done in order to assess the depth of dementia with the short version of MMSE, while evaluation of various variants of FTD was performed with the use of such neuropsychological tests as Newcomb and Chicago Fluency Tests, Wechsler Memory Scale-III (WMS-III), Western Aphasia Battery (WAB-R), and the Boston Naming Test (BNT). Behaviour was evaluated with a Polish version of the Frontal Behavioral Inventory (FBInv). The inventory consists of 24 questions which enable an evaluation of social behaviour disorders. The study included 112 patients--68 men and 46 women treated in the Reintegrative-Training Centre of the Foundation for Persons with Brain Dysfunctions in Kraków and in the Clinic for Developmental Psychiatry, Psychotic Disorders and Old Age Psychiatry, of the Medical University at Gdansk, who were suffering from various types of dementia. RESULTS: It was found that FTD patients scored the highest, while the VAD patients scored somewhat lower in the FBInv. At the same time the scores obtained by PPA patients were higher in comparison to the control groups, but not as high as in the case of patients with FTD. In the process of the neurotherapy of FTD patients we found a reduction of the behavioral disturbances, despite the progression of the illness. CONCLUSIONS: The results obtained in the present study confirmed the diagnostic value of FBInv in the differential diagnosis of various types of FTD and in the evaluation of neurotherapy efficacy.

Reintegrating space and object representations in patients with hemispatial neglect: two case studies.

PURPOSE: This article examines the effectiveness of differentiated rehabilitation programmes for patients with two distinct types of hemispatial neglect: body-centred and object-focused. We hypothesized that patients with body-centred neglect would respond to motor-control programmes designed for patients with limb apraxia, while those with object-focused neglect would require visually oriented therapy. MATERIAL AND METHODS: The article describes the rehabilitation of two patients treated by the authors 6-9 months after right-hemisphere infarct. Both showed significant left-sided hemispatial neglect: body-centred in one case (patient BC), object-focused in the other (patient OF). A modified AB-BA experimental design was used, where A represents visual training, and B is spatio-motor training. For patient BC, the sequence was A-B; for patient OF, B-A. Neglect was measured using standard tests for neglect and the analysis of drawings made during therapy by both patients. RESULTS: As hypothesized, patient BC showed no progress after conclusion of programme A, while after programme B she showed virtually no lingering neglect. In the case of patient OF, the results were exactly reversed. CONCLUSIONS: Body-centred neglect is essentially a defect in space formation, while object-focused neglect is a disorder of object formation. The patients described here both benefited from neuropsychological therapy for neglect, but not from the same programme.

The analgesic effectiveness of laser therapy in patients with gonarthrosis: an evaluation.

Background. Osteoarthrosis is a very common disease of the musculo-skeletal system. Laser therapy can be used to alleviate the pain associated with this syndrome, which markedly impinge the patients physical comfort and limit physical activity. Material and methods. The research involved 32 patients (26 women and 6 men, average age 57.3 A+/-12.1 years) with pain complaints in one knee joint and radiologically confirmed degenerative changes. The control group consisted of 32 matched patients awaiting treatment. Laser biostimulation was applied with a semiconductor laser (400 mW, wave length 810 nm). Contact (point) irradiation was applied, with a surface energy density of 12.7 J/cm2. One series of 10 procedures was performed on one knee joint, 5 days a week. Pain intensity was evaluated with the Visual Analogue Scale (VAS) and a modified version of the Laitinen questionnaire. Results. In 29 patients (91%) there was a statistically significant reduction in pain complaints in the affected knee measured by VAS. In 19 patients (59%) there was a statistically significant reduction in the frequency and intensity of pain complaints on the Laitinen questionnaire. The improvement in daily motor activity and the reduced use of antalgesic drugs were not statistically significant. Conclusions. Laser biostimulation in patients with knee pain reduces symptoms on the VAS, and significantly reduces the intensity and frequency of pain as assessed by the Laitinen questionnaire. One series of laser treatments has no significant effect on motor activity and use of painkillers in patients with chronic knee pain due to osteoarthrosis.

Proprioception as one of the factors deciding on the model of rehabilitation after reconstruction of ACL.

Injuries of the knee joint with ACL tears are causing frontal instability of the knee. In cases of second and third degree instability it is advised to operate - reconstruction of anterior crucial ligament. The operation is the beginning of a rehabilitation program. It is very importand to rebuild static and dynamic proprioception of the knee. In the paper we present most recent opinions on that problem. We explain the role of proprioception on the knee function, also we present a hypothetical model of rehabilitation programme in different activity.

Role of semantic control of action in the comprehensive rehabilitation of patients recovering from prolonged post-traumatic coma.

BACKGROUND: Apraxia, broadly understood as the acquired inability to perform learned, skilled movements not caused by paresis or incomprehension, occurs with greater frequency among patients recovering from prolonged post-traumatic coma than has previously been reported. The present article prevents an evaluation of the effectiveness of a rehabilitation program called Semantic Priming, aimed at rebuilding praxis in these patients. MATERIAL/METHODS: Out of a consecutive series of 51 patients with post-traumatic coma lasting longer than 4 weeks treated at the centers represented by the authors, 24 were found to have pathological scores on the Boston Test of Praxis. These patients were divided into two matched groups, of whom the experimental group received the Semantic Priming program (involving the systematic use of verbal cues to prime movement activation patterns), and the control group did not. Progress was measured by the Boston Test of Praxis and a test developed by the authors on the basis of Luria's procedure for testing praxis. RESULTS: After 5 weeks of therapy the patients in the experimental group showed significantly greater improvement in all measured parameters (p<0.001). CONCLUSIONS: Apraxia in the broader sense is a more common problem among post-coma patients than heretofore recognized, and causes concrete problems in rehabilitation and adjustment to daily living. Our program based on the use of semantic priming of activation proved to be highly successful in remediating apraxia in these patients.

Rehabilitation outcome in a patient awakened from prolonged coma.

BACKGROUND: This article describes the rehabilitation of a patient recovering from a prolonged coma (defined as lasting longer than 4 weeks). The case is noteworthy because it exemplifies the possibilities and difficulties entailed in treating these patients, who are often regarded as too severely impaired to justify intensive rehabilitation efforts. CASE REPORT: The patient is a 28-year old Polish male, unmarried, who suffered serious closed head injuries in an automobile accident in April of 1999. He was in a comatose state for more than two months, with a GCS score of 5. When admitted for rehabilitation he was bedridden, with global aphasia, agraphia, limb apraxia, and executive dysfunction. The rehabilitation program developed for him is described in detail. RESULTS: Over the course of rehabilitation, which began in December 1999 and continues to this writing, the patient has regained locomotion capabilities (though with impairments), and his speech has improved considerably. The apraxia has largely resolved, and he is able to write his name and copy words. He is now capable of performing many activities of daily living. CONCLUSIONS: A comprehensive program of rehabilitation characterized by a strategic, heuristic approach is capable of achieving a good outcome even in very difficult cases, such as prolonged coma.

The course of vision disturbances in a patient with the MELAS syndrome.

BACKGROUND: This article describes the neuropsychological and ophthalmic symptoms presented by a patient with MELAS, a mitochondrial cytopathy. This rare disease is characterized by a remitting-relapsing course against the background of a slowly progressive degenerative process. CASE REPORT: The patient is a 22-year-old Polish female, with initial onset of symptoms in 1994; the clinical diagnosis of MELAS was established in 1998, and confirmed in 2000 by the discovery of a novel mtDNA mutation. Her visual acuity fluctuates from near-normal to near-blindness, often changing dramatically within a matter of weeks; the visual field has more or less steadily narrowed to lunate. Visual evoked potentials show sporadic disturbances, while the nerve fiber layer shows significant attenuation. The evidence points to a complex etiology, involving both cortical damage and attenuation of the optic nerves and neural pathways. A similar two-phase pattern--episodic disturbances with rapid spontaneous recovery against a background of progressive deterioration--occurs in neuropsychological testing, which reveals progressive dementia and episodic aphasia. CONCLUSIONS: The peculiar pathomechanism of MELAS results in simultaneous insults to various parts of the central and peripheral nervous systems, creating the complex and highly variable pattern seen in this patient. In clinical practice care should be taken not to overlook the possible significance of such a pattern appearing in various systems and on varying levels.

Active and passive executive function disorder subsequent to closed-head injury.

BACKGROUND: Executive dysfunction is one of the most destructive sequelae of closed head injuries (CHI), often impeding or even preventing the patient's return to normal functioning. On the basis of extensive clinical testing of patients with neurobehavioral disturbances resulting from CHI, the authors propose a new typology of executive dysfunction based on the primary behavioral distinction between active ('acting without thinking') and passive ('thinking without acting') forms of executive function disorder. MATERIAL/METHODS: Two patients were selected for detailed presentation. Both present with mild to moderate motor and cognitive symptoms resulting from closed head injury. The medical histories of the two patients are similar (educated professionals, mid-40s, married with children, injuries suffered in a traffic accident, 2 months in coma) except for the location of focal injuries. RESULTS: Despite considerable progress in rehabilitation, the extent of functional disorder is disproportionately large in comparison to the degree of objective disability measured by standard instruments. It is suggested that the reason for this disparity lies in executive dysfunction. In particular, a model for executive functioning will be presented to explain why and how selective destruction of particular anatomical/functional components leads to the behavioral consequences known as 'executive dysfunction'. CONCLUSIONS: Executive dysfunction is a distinct clinical syndrome which occurs in at least two distinguishable varieties, active and passive.

Selected physical and biophysical properties of ultrasonic waves used in physical therapy.

This article presents a review of the current literature on the impact of ultrasonic waves widely used in physiotherapy. There is also a presentation of therapeutic indications contraindications, with particular attention to phonophoresis.

Gram-positive microorganisms isolated from patients treated in the Department and Clinic of Rehabilitation at Rydygier Medical University in Bydgoszcz, Poland, 2000-2001.

Background. The purpose of our study was to evaluate the occurrence of Gram-positive microorganisms isolated from patients hospitalized in the Department and Clinic of Rehabilitation at the Rydygier Medical University in Bydgoszcz. Materials and methods. The material analyzed consisted of 533 clinical samples collected from patients hospitalized in 2000-2001. The study included 485 Gram-positive bacterial strains isolated from clinical material. Morphological characteristics provided the basis for the identification of bacteria. The species were identified by using API 20 STREP and API STAPH tests (bioMerieux). The isolates were screened for antimicrobial susceptibility by the disk-diffusion method. Results. The most often isolated bacteria were Enterococcus spp. (46,8%) and Staphylococcus spp. (31,5%), followed by Corynebacterium spp. (9,1%) and Streptococcus spp. (6,6%). The most frequently identified Enterococcus species were E. faecalis (92,9%) and E. faecium (7,1%). All the Enterococcus strains were susceptible to glycopeptides. More than 90% of the Enterococus isolates were sensitive to nitrofurantoine, about 44% to high concentrations of gentamycin, 17,9% to ciprofloxacin. During this period, and S. simulans, and 21 strains of S. auerus (46,7%). 92% of all the tested CNS strains (80%) than in the S. aureus isolates (10%). Conclusions. The most frequently observed bacterium was E. faecalis, which showed significant resistance to quinolones and to high level aminoglycosides. The CNS strains showed a high level of resistance to methicilline. All these strains were susceptible to glycopeptides.

Differential diagnosis of frontal syndrome in patients with closed-head injuries.

Background. A common sequela of head injury is "frontal syndrome", consisting in characteristic neurobehavioral disturbances. However, there is no ecologically valid research tool that would clearly indicate the presence of this syndrome. The goal of this article is to evaluate the authorized the Polish version of the Frontal Behavioral Inventory (FBInv), used to differentiate fronto-temporal dementia (FTD) from other dementias. Material and methods. The research involved 95 patients treated at the centers represented by the authors, divided into 3 groups: CHI, consisting of 39 patients with traumatic frontal lobe injuries; FTD, consisting of 28 patients with fronto-temporal dementia; and a control group of persons with post-traumatic depression without injury to the frontal lobes. The results were based on data obtained from caregivers in 24 categories of patient behavior covered by the FBInv. Results. We found important differences in total scores between patients with frontal syndrome from groups CHI and FTD, as against patients with post-traumatic depression. There are also noticeable differences between patients in group FTD and group CHI in terms of scores on particular test items. Conclusions. The FBInv in the authorized Polish version is both sensitive and specific in measuring neurobehavioral disturbances occurring in patients with post-traumatic damage to the changes in the behavioral and personality of these patients with the passage of time since injury or onset should be the topic of further research.