The structure of participants' turn-transition practices in aided conversations that use speech-output technologies.

Using the concepts and principles of conversation analysis (CA), this paper examines the everyday, unscripted, spontaneous conversations between 4 males who communicated with the aid of speech-output technologies and their mothers. The analyses focused on describing the conversationalists' various actions in aided turn-transition processes, resulting in a 3-part turn-transition structure used to accomplish aided turn initiation. Despite the challenges to conversational progress, the participants did not consider the conversational speed a challenge. The participants and their mothers were oriented to the progression of the aided conversation by creating interaction practices to achieve successful turn-transitions. By understanding the structural characteristics of fluent aided conversations, it may be possible to develop effective interaction strategies for communication partners and for augmentative and alternative communication technologies that are intentionally designed to facilitate interactive communication.

Treatment of Medial Medullary Infarction Using a Novel iNems Training: A Case Report and Literature Review.

Objective. We describe the case of a 66-year-old Japanese male patient who developed medial medullary infarction along with severe motor paralysis and intense numbness of the left arm, pain catastrophizing, and abnormal physical sensation. We further describe his recovery using a new imagery neurofeedback-based multisensory systems (iNems) training method. Clinical Course and Intervention. The patient underwent physical therapy for the rehabilitation of motor paralysis and numbness of the paralyzed upper limbs; in addition, we implemented iNems training using EEG activity, which aims to synchronize movement intent (motor imagery) with sensory information (feedback visual information). Results. Considerable improvement in motor function, pain catastrophizing, representation of the body in the brain, and abnormal physical sensations was accomplished with iNems training. Furthermore, iNems training improved the neural activity of the default mode network at rest and the sensorimotor region when the movement was intended. Conclusions. The newly developed iNems could prove a novel, useful tool for neurorehabilitation considering that both behavioral and neurophysiological changes were observed in our case.

Beyond the gaze: Communicating in chronic locked-in syndrome.

OBJECTIVE: Locked-in syndrome (LIS) usually follows a brainstem stroke and is characterized by paralysis of all voluntary muscles (except eyes' movements or blinking) and lack of speech with preserved consciousness. Several tools have been developed to promote communication with these patients. The aim of the study was to evaluate the current status regarding communication in a cohort of LIS patients. DESIGN: A survey was conducted in collaboration with the French Association of Locked-in syndrome (ALIS). SUBJECTS AND METHODS: Two hundred and four patients, members of ALIS, were invited to fill in a questionnaire on communication issues and clinical evolution (recovery of verbal language and movements, presence of visual and/or auditory deficits). RESULTS: Eighty-eight responses were processed. All respondents (35% female, mean age = 52 ± 12 years, mean time in LIS = 10 ± 6 years) reported using a yes/no communication code using mainly eyes' movements and 62% used assisting technology; 49% could communicate through verbal language and 73% have recovered some functional movements within the years. CONCLUSION: The results highlight the possibility to recover non-eye dependent communication, speech production and some functional movement in the majority of chronic LIS patients.

Huffman and linear scanning methods with statistical language models.

Current scanning access methods for text generation in AAC devices are limited to relatively few options, most notably row/column variations within a matrix. We present Huffman scanning, a new method for applying statistical language models to binary-switch, static-grid typing AAC interfaces, and compare it to other scanning options under a variety of conditions. We present results for 16 adults without disabilities and one 36-year-old man with locked-in syndrome who presents with complex communication needs and uses AAC scanning devices for writing. Huffman scanning with a statistical language model yielded significant typing speedups for the 16 participants without disabilities versus any of the other methods tested, including two row/column scanning methods. A similar pattern of results was found with the individual with locked-in syndrome. Interestingly, faster typing speeds were obtained with Huffman scanning using a more leisurely scan rate than relatively fast individually calibrated scan rates. Overall, the results reported here demonstrate great promise for the usability of Huffman scanning as a faster alternative to row/column scanning.

Noninvasive brain-computer interface enables communication after brainstem stroke.

Brain-computer interfaces (BCIs) provide communication that is independent of muscle control, and can be especially important for individuals with severe neuromuscular disease who cannot use standard communication pathways or other assistive technology. It has previously been shown that people with amyotrophic lateral sclerosis (ALS) can successfully use BCI after all other means of independent communication have failed. The BCI literature has asserted that brainstem stroke survivors can also benefit from BCI use. This study used a P300-based event-related potential spelling system. This case study demonstrates that an individual locked-in owing to brainstem stroke was able to use a noninvasive BCI to communicate volitional messages. Over a period of 13 months, the participant was able to successfully operate the system during 40 of 62 recording sessions. He was able to accurately spell words provided by the experimenter and to initiate dialogues with his family. The results broadly suggest that, regardless of the precipitating event, BCI use may be of benefit to those with locked-in syndrome.

Functional recovery and rehabilitation of postural impairment and gait ataxia in patients with acute cerebellar stroke.

Studies about recovery from cerebellar stroke are rare. The present study assessed motor deficits in the acute phase after isolated cerebellar stroke focusing on postural impairment and gait ataxia and outlines the role of lesion site on motor outcome, the course of recovery and the effect of treadmill training. 23 patients with acute and isolated cerebellar infarction participated. Deficits were quantified by ataxia scores and dynamic posturography in the acute phase and in a follow up after 2 weeks and 3 months. MRI data were obtained to correlate lesion site with motor performance. Half of the patients that gave informed consent and walked independently underwent a 2-week treadmill training with increasing velocity. In the acute phase patients showed a mild to severe ataxia with a worse performance in patients with infarction of the superior in comparison to the posterior inferior cerebellar artery. However, after 3 months differences between vascular territories were no longer significant. MRI data showed that patients with larger infarct volumes had a significantly more severe ataxia. In patients with ataxia of stance, gait and lower limbs lesions were more common in cerebellar lobules IV to VI. After 3 months a mild ataxia in lower limbs and gait, especially in gait speed persisted. Because postural impairment had fully recovered, remaining gait ataxia was likely related to incoordination of lower limbs. Treadmill training did not show significant effects. Future studies are needed to investigate whether intensive coordinative training is of benefit in patients with cerebellar stroke.

[Modified tracheostomy management: a protocol for the application of stoma buttons in difficult decannulations]. / Modifiziertes Trachealkanülenmanagement: Platzhaltereinsatz als Option bei erschwerten Dekanülierungen (Pilotprojekt REHAB Basel).

Current approaches to decannulation management often fail to account for patients with combined swallowing and respiratory deficits. We expanded our existing weaning and decannulation protocol by adding an optional 3-day decannulation trial to evaluate readiness for decannulation. If a patient meets predefined test-decannulation criteria a tracheostomy button is inserted during a laryngoscopic examination and left in situ for up to 3 days. Before, during and after button insertion the patient's respiratory function and saliva management are closely monitored before the decision for or against permanent decannulation is made. We present evaluation criteria, protocols and flow-charts illustrating the 3-day decannulation trial as well as 2 case studies.

Unlocking the locked in; a need for team approach in rehabilitation of survivors with locked-in syndrome.

OBJECTIVES: A stroke that affects the medulla oblongata and/or pons can result in tetra pareses and paralysis of the lower cranial nerves while other parts of the brain remain intact, thus locking the person in. The incidence and prevalence is not known. The aim of this article is to communicate the need for and benefits of a comprehensive rehabilitation and a standardized way of approaching the locked-in person. MATERIAL AND METHODS: To illustrate the rehabilitation process, we present four cases to highlight the needs of the person and what is required of the team. RESULTS: Communication at arrival: three persons communicated through eye movement, one by weak voice. At follow-up (1-6 years later): computer assisted communication was used by two persons, a letter board by one and 'ordinary communication' by one. CONCLUSIONS: There is a need for follow-up not only to re-assess skills and needs partly owing to new technologies but also to see whether the person needs more assistance to adapt to the alternative means of communication or whether the carers of the person need extra information about communication. We conclude that the low incidence of the syndrome necessitates a skilled team in which different professionals can together assess the person. This probably requires some centralization.

Functional outcome in patients with pontine infarction after acute rehabilitation.

We examined the clinical features of patients with pontine infarction in the acute stage and the factors affecting functional prognosis and outcome. Lesions, neurological manifestations at initial physical status examinations, cognitive function, swallowing function and outcome [activities of daily living (ADL), status of nutritional intake at discharge and destination after discharge] were evaluated in 68 patients (47 males and 21 females) who had pontine lesions with acute phase cerebral infarction. The mean length of stay was 24.4 days. The symptoms (number of patients) observed included paralysis (50), dysarthria (47), ataxia (18), diplopia (11), dysphagia (49) and poor cognitive performance (37). The types of lesions (number of patients) included lacunar infarcts in the ventral pontine area (15), lacunar infarcts in the dorsal pontine area (13) and large lacunar infarcts (LLIs) (41). After hospital discharge, 23 patients were discharged home, 44 were transferred to another hospital and 1 died. Twenty-three patients were on a regular diet, 22 were receiving a dysphagia diet and 22 were on enteral feeding at discharge. Patients with LLIs more frequently had poor cognitive performance, paralysis, dysphagia at discharge and a tendency for a longer length of stay compared with patients who had lacunar infarct. Most patients who returned home were those who were younger in age, had fewer neurological symptoms, had better cognitive function and ADL performance, and could ingest food. In an acute hospital, age, neurological symptoms, ADL, cognitive function, and dysphagia were considered important factors for determining the outcome in patients with pontine infarction.

Stuttering after right cerebellar infarction: a case study.

UNLABELLED: We report a male patient with neurogenic stuttering after cerebellar infarction. He had suffered from frontal and thalamus damage and he had exhibited aphasia, but his speech had been fluent until onset of the cerebellar infarction. Results of analysis of speech samples included the following: (1) the patient showed very frequent syllable repetition and part-word repetition. (2) The stuttering occurrence rate at the second test was much higher than at the first test. (3) Almost all stuttering occurred on initial word sounds; stuttering on the medial and final word was less frequent. (4) Adaptation effect was absent. (5) Secondary behaviors such as closing of the eyes and grimacing were observed. The internal model related to cerebellar functions can be modified using feedback-error information. Results suggest that internal model dysfunction caused this patient's stuttering. EDUCATIONAL OBJECTIVES: After reading this text, the reader will be able to: (1) provide characteristics of neurogenic stuttering after the cerebellum infarction; (2) discuss the relationship between neurogenic stuttering and functions of the cerebellum.

Progression of pathological changes in the middle cerebellar peduncle by diffusion tensor imaging correlates with lesser motor gains after pontine infarction.

BACKGROUND: Wallerian degeneration in pyramidal tract following supratentorial stroke has been detected by some studies using diffusion tensor imaging (DTI), but the Wallerian degeneration in middle cerebellar peduncle after pontine infarction and its potential clinical significance remain to be confirmed. METHODS: Seventeen patients with a recent focal pontine infarct underwent 3 DTIs at week 1 (W1), week 4 (W4), and week 12 (W12) after onset. Seventeen age-matched and gender-matched controls underwent DTI one time. Mean diffusivity and fractional anisotropy (FA) were measured in the basis pontis and bilateral middle cerebellar peduncles. Neurological deficit, motor deficit, functional independence, and limbs ataxia were assessed with the National Institutes of Health (NIH) Stroke Scale, Fugl-Meyer scale, Barthel Index, and the second part of International Cooperative Ataxia Rating Scale. RESULTS: FA values at the bilateral middle cerebellar peduncles decreased significantly from W1 to W12 progressively (P<.01). The patients improved on the NIH Stroke Scale, Fugl-Meyer scale, and Barthel Index over time (P<.01). Greater absolute value of percentage reduction of FA at the bilateral middle peduncles, however, was associated with the less absolute value of percentage reduction of the NIH Stroke Scale and less increase in the Fugl-Meyer scale, as well as greater ataxia over time. CONCLUSIONS: Wallerian degeneration in the middle cerebellar peduncle revealed by DTI may hinder the process of neurological recovery following a focal pontine infarct.

The rehabilitation of patients recovering from brainstem strokes: case studies and clinical considerations.

An estimated 15% of all patients admitted to stroke rehabilitation units experience a brainstem stroke. Two case studies are presented to illustrate some of the difficulties encountered in the rehabilitation of these individuals. Unlike hemispheric stroke, the characteristic consequences of brainstem stroke include ataxia, dysarthria, and diplopia. Additionally, individuals with brainstem stroke may suffer from severe dysphagia and may require enteral feedings. Unlike the rehabilitation of patients with hemispheric stroke, where there is an impressive and relatively comprehensive research literature, there has been surprisingly little research published on the rehabilitation of patients with brainstem stroke despite the fact they represent a significant number of patients admitted to stroke rehabilitation units.

Medial medullary infarction: a role of diffusion-weighted magnetic resonance imaging for stroke rehabilitation.

We report a patient with medial medullary infarction who could be diagnosed in an early stage, and we discuss the role of diffusion-weighted magnetic resonance imaging (MRI) for stroke rehabilitation. In the case of our patient, the infarction was difficult to diagnose because the patient had atypical features and a past history of head injury. Nonetheless, we could diagnose the medial medullary infarction easily using diffusion MRI within several hours of onset. Then, a rehabilitation program was started the day after onset. We believe that diffusion MRI can be used as a useful method for very early stage diagnosis and to execute rehabilitation for early stroke patients.

Cognitive dysfunction after isolated brain stem insult. An underdiagnosed cause of long term morbidity.

Cognitive dysfunction adversely influences long term outcome after cerebral insult, but the potential for brain stem lesions to produce cognitive as well as physical impairments is not widely recognised. This report describes a series of seven consecutive patients referred to a neurological rehabilitation unit with lesions limited to brain stem structures, all of whom were shown to exhibit deficits in at least one domain of cognition. The practical importance of recognising cognitive dysfunction in this group of patients, and the theoretical significance of the disruption of specific cognitive domains by lesions to distributed neural circuits, are discussed.

Clinical characteristics of patients with brainstem strokes admitted to a rehabilitation unit.

OBJECTIVE: To examine the clinical characteristics of patients with brainstem strokes admitted to a rehabilitation unit. DESIGN: Retrospective cohort. SETTING: Inpatient rehabilitation unit. PARTICIPANTS: Eighty-five consecutive admissions (56 men, 29 women; mean age, 61.9+/-14.4y; range, 18-85y) with radiologically confirmed focal evidence of specific lesions within the pons, midbrain, cerebellum, and medulla. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Various clinical characteristics, including stroke-related deficits and stroke risk factors, were identified and compared between brainstem subgroups. The incidence of complications, including pneumonia, deep vein thrombosis, and seizure disorder, was also reported. RESULTS: Seventy (82%) of the strokes resulted from infarctions and 15 (18%) were caused by hemorrhages. The functional deficits of hemiparesis, ataxia, and diplopia were present in 41 (48%), 73 (86%), and 32 (38%) patients, respectively. Dysarthria was reported in 42 patients (49%) and dysphagia in 40 (47%). Pneumonia during hospitalization was a complication in 9 (11%) of the patients with brainstem stroke. The risk factors of diabetes and hypertension were present in 22 (26%) and 47 (55%) patients, respectively. Fourteen (17%) of these patients had suffered a previous stroke. CONCLUSIONS: Rehabilitation patients experience a variety of functional impairments as a consequence of brainstem stroke. These include hemiparesis, dysarthria and dysphagia, diplopia, and ataxia. A significant number of patients had pneumonia as a complication. The characteristics and impairment profiles of patients within the subgroups were similar, with the exception of the incidence of ataxia and hemiparesis.