Bedside diagnosis of silent aspiration using mobile dynamic digital radiography: a preliminary study.

PURPOSE: This study aimed to assess reliable options for bedside diagnosis of silent aspiration in the intensive care unit by examining the use of default grayscale images (DGI) obtained using a mobile, general-purpose, radiography system capable of dynamic digital radiography (M-DDR) and inverted grayscale images (IGI) of DGI. METHODS: This cohort study (exploratory and preliminary) involved 18 adult patients (mean age, 89.0 years) for whom a swallowing assessment request was received from their primary physicians. Fifty-six IGI videoclips were evaluated by three specialists using the penetration-aspiration scale (PAS), with the gold standard being the consensus reading of all three specialists. Another three speech-language pathologists (SLPs) assessed 56 DGI and IGI videoclips using the PAS. PAS scores 1 and 2 were classified as normal range, PAS scores 3-5 as pathological laryngeal penetration, and PAS scores 6-8 as aspiration. The correct rates with IGI and DGI were then determined, and the level of agreement of IGI and DGI evaluations was evaluated. RESULTS: The correct rate of all evaluators was 100% for normal range, 80-100% for pathological laryngeal penetration, and 83-100% for aspiration with IGI and 100% for normal range, 90% for pathological laryngeal penetration, and 83% for aspiration with DGI. The kappa coefficient for IGI and DGI showed almost complete agreement for abnormal conditions. CONCLUSION: Dynamic imaging of swallowing 2-5 ml of liquid using M-DDR performed for elderly patients at the bedside showed that aspiration assessments by SLPs obtained from DGI videos immediately after imaging are acceptable.

Recovery of respiratory muscle strength, physical function, and dyspnoea after lobectomy in lung cancer patients undergoing pulmonary rehabilitation: A retrospective study.

OBJECTIVE: To characterise changes in respiratory muscle strength, physical function, and dyspnoea in patients who underwent pre- and post-operative exercise intervention following lobectomy for non-small-cell lung cancer (NSCLC). METHODS: This retrospective study included NSCLC patients who underwent lobectomy via video-assisted thoracoscopic surgery (VATS) or posterolateral thoracotomy (PLT) and pre- and post-operative exercise intervention consisting of breathing, flexibility, resistance, aerobic exercises, coughing/huffing techniques, and early mobilisation. Maximum mouth inspiratory (Pimax) and expiratory pressures (Pemax), 6-min walk distance (6MWD), quadriceps force (QF), and modified Medical Research Council (mMRC) dyspnoea scale were evaluated preoperatively, at hospital discharge, and post-lobectomy 1 and 3 months. RESULTS: Data from 41 patients were analysed. At hospital discharge, the Pimax, Pemax, 6MWD, and mMRC dyspnoea scores were lower than pre-operatively; QF remained unchanged; Pimax and 6MWD recovered to pre-operative values at post-lobectomy 1 month; and Pemax and mMRC dyspnoea scores recovered at 3 months. During sub-analysis, Pimax and mMRC dyspnoea scores in the VATS (n = 24) and PLT groups (n = 17) recovered to pre-operative values at post-lobectomy 1 and 3 months. CONCLUSION: After lobectomy, respiratory muscle strength, physical function, and dyspnoea in patients who underwent exercise intervention returned to pre-operative values at post-lobectomy 3 months.

[Rehabilitative Intervention for Attentional Disturbance].

Several evidence-based guidelines of rehabilitative intervention for attentional disturbance following acquired brain injury have been published. The author introduced two cutting-edge guidelines: Japan Stroke Society Guideline 2021 for the Treatment of Stroke [Revised version 2023]; and INCOG 2.0 Guideline for Cognitive Rehabilitation Following Traumatic Brain Injury, PartII: Attention and Information Processing Speed (2023). The effect of the cognitive rehabilitation should be evaluated by change of performance in real-world tasks and activities as well as measures of various neuropsychological tests including paced auditory serial addition task (PASAT) and trail making test. Direct attention training such as Attention Process Training (APT) series or computer-based training may be useful especially for stroke patients. Dual-task training may specifically improve multi-tasking performance. Time pressure management can improve speed of performance on everyday tasks for patients with slowed information processing. Metacognitive training using everyday activities may be recommended for mild to moderate impairments. Modifications of environment and/or tasks may also be helpful to decrease errors in daily activities.

Relationship between Clinical Severity and Cross-sectional Area of Ultrasonographic Examinations in Ulnar Neuropathy at the Elbow.

Objectives: This study explored the relationship between clinical severity of ulnar neuropathy at the elbow (UNE) and ulnar nerve cross-sectional area (CSA) by ultrasound examination to identify appropriate measurement sites for UNE diagnosis and evaluation. Methods: In this retrospective analysis, we examined the arms of 37 patients diagnosed with UNE and those of 34 individuals as controls. The ulnar nerve CSAs were measured at 2 cm distal to the tip of the medial epicondyle (dME), the tip of the medial epicondyle (ME), 2 cm proximal to the tip of the medial epicondyle (pME), and any site showing the maximum CSA between the dME and pME (largest dpME). The modified McGowan classification (grades I, IIA, IIB, and III) was used to rate the clinical severity of UNE. Results: For all sites, the CSAs were significantly correlated with clinical severity. The sites showing the maximum CSA were inconsistent between controls and grade IIA patients. Grade IIB patients showed the largest CSA at the ME in the majority of patients. In grade III patients, maximum CSA occurred only at the ME. Conclusions: Serial assessment to detect nerve enlargement at multiple sites was beneficial for mild UNE patients with weakness of the ulnar distal muscles with Medical Research Council (MRC) score of 4 or higher (grade IIA). For severe UNE patients with weakness of the ulnar distal muscles classified as MRC3 or less (grades IIB, III), the most efficient method for detecting enlarged nerves was to initially measure the CSA at the ME.

Sniff and reverse-sniff nasal respiratory pressures after exacerbation of chronic obstructive pulmonary disease: A single-center prospective study.

BACKGROUND: and objective: This study examined the validity of sniff nasal inspiratory (SNIP) and reverse-sniff nasal expiratory pressures (RSNEP) for estimating respiratory muscle strength and for predicting poor life expectancy following exacerbation in patients with chronic obstructive pulmonary disease (COPD). METHODS: This prospective study included patients who were admitted for COPD exacerbation and underwent rehabilitation. At hospital discharge, SNIP, RSNEP, and maximum mouth inspiratory (MIP) and expiratory pressures (MEP) were measured, and the body mass index, degree of airflow obstruction, dyspnea, and exercise capacity (BODE) index was calculated by evaluating body mass index, forced expiratory volume in 1 s (FEV1), the Modified Medical Research Council Dyspnea Scale, and 6-min walk distance. RESULTS: Data from 43 patients (mean age 76.8 years, FEV1 42.8 % predicted) were analyzed. SNIP and RSNEP were moderately correlated with MIP and MEP, respectively. Bland-Altman plot means of SNIP (48.3 ± 17.5) and RSNEP (44.7 ± 23.8 cmH2O) were lower than those of MIP (54.8 ± 19.9) and MEP (76.4 ± 31.2 cmH2O), respectively, and the SNIP-MIP and RSNEP-MEP 95 % limits of agreement were wide. Logistic regression showed that SNIP and RSNEP were significantly associated with BODE score ≥7 (poor life expectancy), and predictive accuracy was 81.4 % when combining SNIP ≤49 and RSNEP ≤42 cmH2O. CONCLUSION: After exacerbation in patients with COPD, SNIP and RSNEP are useful indicators that complement MIP and MEP. Furthermore, a combined SNIP and RSNEP test may be beneficial in predicting poor life expectancy.

Successful Treatment with the Chin-down Maneuver of Dysphagia Secondary to Descending Necrotizing Mediastinitis: A Case Study.

BACKGROUND: Descending necrotizing mediastinitis is a potentially fatal polymicrobial infection that often leads to dysphagia after treatment. Such dysphagia is likely the result of fibrosis and scarring from inflammatory changes in the fascial space. A case is presented in which the mechanism of dysphagia was verified using two-dimensional analysis of the muscle lengths of the suprahyoid and infrahyoid muscles. CASE: A 57-year-old woman presented with a hyoid and laryngeal movement disorder with pharyngeal residue secondary to descending necrotizing mediastinitis. To treat this disorder, the chin-down maneuver was performed, and it immediately improved hyoid and laryngeal elevation and reduced pharyngeal residue at the epiglottic valleculae and pyriform sinus. Analysis of the mechanism of these improvements revealed that combined head and neck flexion, compared with neck flexion, decreased the distance between the origin and insertion (DOI) of the sternohyoid muscle (SM) and increased the muscle contraction rate and the maximum contraction duration of the geniohyoid muscle (GM) during swallowing. DISCUSSION: In the present case, the patient had restrictions in extension of the SM that applied resistance to GM contraction. Compensation of this condition was achieved by combined head and neck flexion, which decreased the DOI of the SM, thereby improving the contractile function of the GM.

The Clinical Efficacy of Botulinum Toxin Injections to the Upper Lumbrical Muscles for Clenched Fist Deformity in Chronic Stroke Patients.

OBJECTIVE: Post-stroke hemiplegic patients with a spastic clenched fist deformity that was caused by upper motor neuron syndrome often have problems with hygiene and nursing. Botulinum toxin-A (BTX-A) had been given for treatment of such patients to relieve spasticity by targeting finger joint muscles, such as the flexor digitorum superficialis and flexor digitorum profundus. However, some of these patients do not have satisfactory outcomes. Therefore, we aimed to examine the clinical efficacy and outcome of BTX-A treatment that targeted the upper lumbrical muscles (ULM) in patients with spastic clenched fist deformity caused by stoke. METHODS: Chronic stroke patients with spastic clenched fist deformity who received BTX-A treatment were evaluated retrospectively. We obtained data from medical records before and at 4 weeks after BTX-A injection to the ULM. The clinical data and outcome measures analyzed included range of motion, the Modified Ashworth Scale, the numeric graphic rating scale for pain, and 2 items from the disability assessment scale (ease of cleaning palm and trimming nail). RESULTS: Wilcoxon signed rank test showed that BTX-A treatment significantly improved all measures. CONCLUSION: BTX-A therapy to the ULM provided satisfactory outcomes in improving spastic clenched fist.

Clinical significance of an easy-to-use dual task for assessing inattention.

Purpose To investigate clinical significance of a newly developed paper-and-pencil type dual-task (Oiso-DT) for assessing inattention of brain-damaged patients. Methods A total of 134 healthy individuals and 44 patients with traumatic brain injury (TBI) were the subjects. Oiso-DT combined a cancelation sub-task and a written calculation sub-task on paper. The performance was scored based on the correct rate (CR) and success rate in the cancelation sub-task, and the number of correct answers and CR in the calculation sub-task for three minutes. Performances of Clinical Assessment for Attention (CAT) developed by The Japan Society for Higher Brain Dysfunction were also measured in TBI patients. Results Based on a simple and unique definition of cutoff values, abnormal performance was detected more often in the Oiso-DT than in any sub-task of CAT including Symbol Digit Modalities Test, The Memory Updating Test and Paced Auditory Serial Addition Task, etc. although the specificity was comparable. Conclusion This easy-to-use Oiso-DT might be valuable and sensitive for detecting inattention including mild deficit. Implications for Rehabilitation The Oiso-DT, a paper-and-pencil clinical test for assessing inattention demonstrates higher sensitivity for traumatic-brain-injury patients than standard neuropsychological tests. The task performance is evaluated by a simple and unique method without specific equipment or even a personal computer. The Oiso-DT might be valuable for detecting inattention including mild deficit. The Oiso-DT is easily applicable to patients with severe inattention who failed to complete complex tasks like paced auditory serial addition task.

Proposal for a Modified Jaw Opening Exercise for Dysphagia: A Randomized, Controlled Trial.

OBJECTIVE: To verify the feasibility and effectiveness of a newly developed modified jaw opening exercise (MJOE) in post-stroke patients with pharyngeal residue who completed a sixweek exercise regimen. DESIGN: Double-blind, randomized, controlled trial. PARTICIPANTS: 16 patients with stroke-related dysphagia. INTERVENTIONS: Participants were allocated to an intervention group (MJOE: one set of five repetitions at 80% maximum voluntary contraction (MVC) for 6 seconds) or a control group (isometric jaw closing exercise: one set of five repetitions at 20% MVC for 6 seconds). Each group performed four sets a day, five times a week, for a total of six weeks. MAIN OUTCOME MEASURES: A videofluorographic swallowing study was performed before and after exercise. The distance between the mental spine and the hyoid bone (DMH) and hyoid displacement (HD) were measured. RESULTS: Twelve participants completed the study. No pain in the temporomandibular joint and/or anterior region of the neck occurred during the exercise period. In the intervention group (N=6), a decrease in DMH where anterior HD ended and an increase in anterior HD were seen. In the control group (N=6), no changes were seen. CONCLUSIONS: MJOE is feasible without any adverse events in poststroke patients, and it promotes anterior HD during swallowing.

Efficacy of Tape Feedback Therapy on Synkinesis Following Severe Peripheral Facial Nerve Palsy.

BACKGROUND: Mirror feedback rehabilitation is effective in preventing the development of oro-ocular synkinesis following severe facial palsy. However, we do not have effective maneuvers to prevent the deterioration of oculo-oral synkinesis. We developed a new method of biofeedback rehabilitation using tape for the prevention of oculo-oral synkinesis. OBJECTIVE: The aim of the present study was to investigate the efficacy of taping feedback rehabilitation. METHODS: Twelve consecutive patients with peripheral facial nerve palsy who developed synkinesis were divided into 2 groups. Six patients were treated with the new training method, and the remaining 6 patients were treated with conventional therapy as controls. In the experiment group, tape was placed around the mouth, and the patient was instructed to close the eyes so that no movements of the mouth would be perceived from sensations of the taped skin. After 4 weeks of training, facial movements were recorded and movie images were graded for mouth synkinesis using the revised Sunnybrook facial grading system by examiners blinded to patient grouping. RESULTS: Mouth corner contraction during eye closure was significantly weaker in the experimental group than in the control group. CONCLUSIONS: Our new feedback method could help prevent the deterioration of oculo-oral synkinesis.

Proposal for a New Exercise Method for Dysphagia with Velopharyngeal Inadequacy: A Case of Bickerstaff's Brainstem Encephalitis.

Bickerstaff's brainstem encephalitis is an autoimmune disease with the primary lesion situated in the brainstem and three cardinal signs: ophthalmoplegia; ataxia; and impaired consciousness. A 68-year-old man was started on rehabilitation exercise 3 months after onset of Bickerstaff's brainstem encephalitis, due to remnant dysarthria and dysphagia (Functional Oral Intake Scale, level 5) after the cardinal signs of Bickerstaff's brainstem encephalitis resolved. Exercise involved using a straw in the anterior midline between the dorsal tongue and hard palate. While the patient was inhaling through the straw, the straw was blocked. After strengthening suction as much as possible, the patient was asked to immediately dry swallow at the same time that suction was stopped. Effects of exercise were examined using videofluorographic swallowing studies before and after 6 weeks of training to compare posterior and superior velar displacements and the presence of nasopharyngeal reflux. No adverse effects of exercise were encountered, and Functional Oral Intake Scale improved to level 7, with significant increases in posterior and superior velar displacement during swallowing compared with before training. In addition, nasopharyngeal reflux that had consistently been seen on swallowing before training was absent after 6 weeks of exercise. This exercise method may prove useful.

Development of a new mouth opening force test using an indirect cervical traction device.

BACKGROUND AND AIMS: There have been few reports of objective jaw opening tests, and such studies have involved devices specifically designed for research. In the present study, in order to conveniently and objectively assess mouth opening movements, we replaced the manual resistance used in Daniels and Worthingham's muscle test (DMT) with an indirect cervical traction device. We examined whether the maximum mouth opening force (MOF) could be reliably quantified using this device. METHODS: The subjects were 12 healthy individuals with a mean age of 28.8 years. The MOF measurement procedure was as follows: 1) the subject sat in the chair, and a head belt was placed under the chin so that a traction force was applied almost parallel to the body axis; 2) the researcher instructed the subject to maintain the maximum mouth opening; 3) as maximum resistance was approached, the rate of increase in the traction force decreased. Maximum opening force was recorded; 4) one measurement was taken per session, for a total of two measurements per subject. Pearson's correlation coefficients were used to assess the reproducibility of MOF values. RESULTS: The average MOF (mean +/- SD) in the first and second tests was 24.2 +/- 1.9 and 24.5 +/- 2.0 kg. There was an extremely high correlation between first and second measurements (r = 0.969). CONCLUSIONS: The presently described indirect cervical traction device can be used to reliably quantify MOF.

Influence of stimulus intensity on waveform of sympathetic skin response evoked by magnetic stimulation.

OBJECTIVE: The aim of this study was to investigate the influence of stimulus intensity on the waveform of sympathetic skin response (SSR). The origin of the SSR waveform was discussed. METHODS: A total of 12 SSRs from palm skin were analyzed in 40 normal subjects. SSR was evoked by magnetic stimulation to the neck at 3 different intensities (10, 35, and 70% of the maximum output). The 3 stimuli were repeatedly applied in 4 separate sets. Waveforms were classified as either the P type, in which the positive component was larger than the negative one, or the N type, in which the negative component was larger than the positive one. Amplitude values of peak-to-peak, the first negative (N1), and subsequent positive (P1) components were compared among the 12 responses. RESULTS: When the stimulation was increased, the SSR size became larger. The P type SSR was most frequently found in the maximum stimulation. Strong stimulation generally produced a large P1. Only the N type SSR exhibited a large N1 response to the maximum stimulation. There was a significant, negative correlation between N1 peak duration (difference between the SSR onset and N1 peak latencies) and P1 amplitude. CONCLUSIONS: These results suggested that strong responses probably produced a P type SSR with a large P1 component. In this condition, a rapid change of potential from negative to positive prevented any correlation between N1 amplitude and the magnitude of the response. In the N type SSR, however, a large N1 was associated with a strong response. These findings can be explained by a newly presented theory on the neurophysiological origin of the negative and positive components, based on a model of equivalent current dipole dependent on the Na+ concentration gradient. SIGNIFICANCE: The present study provided some suggestions on the neurophysiological mechanism of SSR waveform.

F wave duration in mild S1 radiculopathy: comparison between the affected and unaffected sides.

OBJECTIVES: The aim of this study was to investigate the F wave duration (Fdur) of the tibial nerve in mild S1 radiculopathy. We evaluated the difference in this parameter between the affected and unaffected sides, and discussed the clinical significance of this difference. METHODS: Bilateral tibial F waves were obtained from 46 normal subjects (control group) and 27 patients with L5/S1 intervertebral disc herniation (patient group). Minimum latency of F wave (Fmin) and Fdur were analyzed. RESULTS: Fmin and Fmin corrected by the subject's height (Fmin/H) were both significantly longer on the affected side than on the unaffected side and in the normal group, but the incidence of abnormality was very low for both parameters. Even patient showing normal Fmin or Fmin/H sometimes exhibited Fdur values prolonged beyond the reference range. Judgment of abnormal Fdur based on the difference between the two sides was the most sensitive method for detecting the root injury. No patients showed decreased Fdur. There was no significant difference between the two groups in the amplitude of compound muscle action potential of the abductor hallucis. CONCLUSIONS: Our study suggested that evaluation of the difference in Fdur between the two sides was a valuable means of decreasing false-negative results in F wave study in mild S1 radiculopathy cases.

Activation of pre-supplementary motor area (SMA) and SMA proper during unimanual and bimanual complex sequences: an analysis using functional magnetic resonance imaging.

Several functional imaging studies have shown that the extent of activation and percentage change in cerebral blood flow in the supplementary motor area (SMA) during a bimanual mirror performance of a simple repetitive movement are almost identical to those during a unimanual movement. The aim of this study was to investigate whether this finding was also applicable to a more complex movement. Eight right-handed, healthy volunteers performed unimanually (with their right and left hands) and bimanually (in a mirror fashion) thumb-finger opposition in a nonconsecutive order (index-middle-index-ring-index-little-index-middle ... fingers). The SMA proper was more activated during the bimanual movement than the unimanual movement with either hand. This is in accordance with the hypothesis that bimanual movement, even in a mirror fashion, is more difficult than unimanual movement when the task is complex but not when the task is simple. Pre-SMA was inconsistently activated. The results suggest that the SMA proper plays an active role in executive processing during bimanual mirror performance of complex movements.

Intermanual difference in the Japanese Trail Making Test and its mirror version: intra-subject comparison of the task-completion time, cognitive time, and motor time.

PURPOSE: To investigate intermanual differences in the performance of the Japanese Trail Making Test (JTMT) using an intra-subject comparison, and to investigate how the cognitive and motor times spent in performing the task were related with the total completion time. METHODS: All subjects performed both parts A and B of the following three tasks: JTMT with the right hand (R); JTMT with the left hand (L); and a mirror version of the JTMT with the left hand (M). The order in which these three tasks were performed (RLM, RML, LRM, LMR, MRL, and MLR) was randomly determined. An interval of 4 weeks was scheduled between each examination. In addition to the completion time, we measured 'motor time', a sum of the times for drawing lines to connect the targets, and 'cognitive time', a time obtained by subtracting the motor time from the completion time. RESULTS: The task-completion time was more strongly correlated with the cognitive time than with the motor time. The order of the task performance did not influence the task-completion time. A learning effect was found only between the first and second examinations of part A. The cognitive time for the second and third performances of part A were significantly shorter than that for the first task, whereas the motor time remained unchanged. No intermanual differences in the performance were found in any comparisons. CONCLUSIONS: The non-dominant hand can be used as an alternative hand in the JTMT, and it can be expected to perform comparably to the dominant hand. These findings are consistent with the finding previously obtained by inter-subject comparison. The lack of any significant intermanual difference can be explained by that the total completion time is less influenced by the motor time than by the cognitive time.

A case with acute quadriplegic myopathy following intensive care for idiopathic interstitial pneumonia.

We reported a patient who developed acute quadriplegic myopathy (AQM) following treatment with a combination of high-dose steroid and nondepolarizing blocking agent for idiopathic interstitial pneumonia (IIP). Few cases of AQM with IIP have been reported in the literature. The HP progressed rapidly in our patient, but the high-dose steroid therapy was effective. The rehabilitative intervention comprised of passive range-of-motion exercise, functional training, and muscle strengthening. After the initial presentation with severe weakness, the AQM gradually improved and the patient regained full physical function in 8 months. The clinical course was almost identical to that of AQM patients with other lung diseases. Though unlikely to influence the improvement of muscle weakness in AQM patients, the lung diseases associated with AQM may require specific consideration in determining suitable rehabilitation programs and observing patients before and after full recovery from dysmobility.

Swallowing appliance: intraoral reshaping prosthesis for dysphagia secondary to oral floor cancer: a pilot study.

Patients with oral floor cancer often have difficulty swallowing solid foods. The aim of this study was to improve the propulsion of solid foods using a swallowing appliance (SW-A). Subjects comprised three patients with oral floor cancer who had undergone curative surgery. Each participant was asked to swallow gelatin under three conditions: without an SW-A, with a maxillary SW-A, and with both maxillary and mandibular SW-As. This procedure was repeated thrice with three volumes of gelatin (2.5, 5, and 7.5 ml), with videofluorographic swallowing study. Swallowing was assessed on the basis of whether the participant could propel the gelatin from the oral cavity to the pharynx. No subject could propel 2.5 ml of gelatin to the pharynx without an SW-A or with only a maxillary SW-A in place. When both SW-As were used, all subjects could propel all three volumes of gelatin. The mandibular SW-A complemented the compensatory effects of the maxillary SW-A.

Within-subject consistency of sympathetic-skin-response waveform across different modalities of stimulation.

This study was conducted to investigate the intra-subject consistency of the waveform type and the size of the sympathetic skin response (SSR) evoked by different modalities of stimulation. Thirty-eight normal volunteers were enrolled as subjects. SSRs were obtained using three different modalities of stimulations: auditory (a-SSR), electrical (e-SSR), and magnetic (m-SSR). Four stimuli of each modality were applied. The waveforms were classified into two types, P (positive component larger the than negative component) and N (vice versa). P-type waveforms were less frequent in the a-SSR than in the e- and m-SSR. The occurrence of the respective waveforms and the values of maximum amplitudes were significantly correlated among the SSRs evoked by different types of stimulation. Judging from these results, the SSR waveforms and size seemed to be consistent in individuals. The results also suggested that endogenous factors in an individual related to the development of SSRs e.g., individual's emotional state, susceptibility to the surprise effect, and anatomical characteristic were important determinants of the SSR waveforms and maximum amplitude.

Selective deficit of divided attention following traumatic brain injury: case reports.

Divided attention (DA) impairment may be the most salient and commonly reported cognitive dysfunction following traumatic brain injury (TBI). Even so, DA impairment is sometimes overlooked during hospitalization. Our group experienced two TBI patients with selective deficits of DA recognized after their return-to-work. Neither patient showed abnormalities in standard tests for higher brain dysfunction. Both, however, performed poorly in a newly developed dual-task test. DA should be assessed more thoroughly and carefully in TBI patients. Dual-task testing may be sensitive in the detection of DA disturbances.