Telemedicine-Based Cognitive Examinations During COVID-19 and Beyond: Perspective of the Massachusetts General Hospital Behavioral Neurology & Neuropsychiatry Group.

Telehealth and telemedicine have encountered explosive growth since the beginning of the COVID-19 pandemic, resulting in increased access to care for patients located far from medical centers and clinics. Subspecialty clinicians in behavioral neurology & neuropsychiatry (BNNP) have implemented the use of telemedicine platforms to perform cognitive examinations that were previously office based. In this perspective article, BNNP clinicians at Massachusetts General Hospital (MGH) describe their experience performing cognitive examinations via telemedicine. The article reviews the goals, prerequisites, advantages, and potential limitations of performing a video- or telephone-based telemedicine cognitive examination. The article shares the approaches used by MGH BNNP clinicians to examine cognitive and behavioral areas, such as orientation, attention and executive functions, language, verbal learning and memory, visual learning and memory, visuospatial function, praxis, and abstract abilities, as well as to survey for neuropsychiatric symptoms and assess activities of daily living. Limitations of telemedicine-based cognitive examinations include limited access to and familiarity with telecommunication technologies on the patient side, limitations of the technology itself on the clinician side, and the limited psychometric validation of virtual assessments. Therefore, an in-person examination with a BNNP clinician or a formal in-person neuropsychological examination with a neuropsychologist may be recommended. Overall, this article emphasizes the use of standardized cognitive and behavioral assessment instruments that are either in the public domain or, if copyrighted, are nonproprietary and do not require a fee to be used by the practicing BNNP clinician.

Telemedicine in Behavioral Neurology-Neuropsychiatry: Opportunities and Challenges Catalyzed by COVID-19.

Coronavirus 2019 (COVID-19) has profoundly impacted the well-being of society and the practice of medicine across health care systems worldwide. As with many other subspecialties, the clinical paradigm in behavioral neurology and neuropsychiatry (BN-NP) was transformed abruptly, transitioning to real-time telemedicine for the assessment and management of the vast majorities of patient populations served by our subspecialty. In this commentary, we outline themes from the BN-NP perspective that reflect the emerging lessons we learned using telemedicine during the COVID-19 pandemic. Positive developments include the ability to extend consultations and management to patients in our high-demand field, maintenance of continuity of care, enhanced ecological validity, greater access to a variety of well-reimbursed telemedicine options (telephone and video) that help bridge the digital divide, and educational and research opportunities. Challenges include the need to adapt the mental state examination to the telemedicine environment, the ability to perform detailed motor neurologic examinations in patients where motor features are important diagnostic considerations, appreciating nonverbal cues, managing acute safety and behavioral concerns in less controlled environments, and navigating intervention-based (neuromodulation) clinics requiring in-person contact. We hope that our reflections help to catalyze discussions that should take place within the Society for Behavioral and Cognitive Neurology, the American Neuropsychiatric Association, and allied organizations regarding how to optimize real-time telemedicine practices for our subspecialty now and into the future.

Pain Catastrophizing and Limiting Behavior Mediate the Association Between Anxiety and Postconcussion Symptoms.

BACKGROUND: Despite growing evidence that anxiety is critical in the development and maintenance of postconcussion symptoms after mild traumatic brain injury (mTBI), little is known about potential mechanisms through which anxiety may affect these symptoms. OBJECTIVE: To test the strength and reliability of cognitive (pain catastrophizing) and behavioral (limiting behaviors) pathways mediating the relationship between anxiety and postconcussion symptoms among patients with mTBI. METHOD: Patients with mTBI (N = 57) completed self-report measures of anxiety, postconcussion symptoms, pain catastrophizing, and limiting behavior. After preliminary simple-mediation models (for pain catastrophizing and limiting behavior separately), we ran a multiple-mediation model (pathways modeled simultaneously). Bootstrapping with 10,000 resampling iterations assessed mediation reliability. RESULTS: In preliminary simple mediation models, both pain catastrophizing (ß = 0.24, 95% confidence interval [CI] = 0.03-0.44, P = 0.02) and limiting behaviors (ß = 0.14, 95% CI = 0.03-0.26, P = 0.01) partially mediated the relationship between anxiety and postconcussion symptoms. In the multiple mediation model, pain catastrophizing was a less reliable but numerically stronger mediator (ß = 0.19, 95% CI = -0.01 to 0.38; P = 0.05) and explained more variance in postconcussion symptoms (R2 = 0.41) than limiting behavior (ß = 0.10, 95% CI = 0.02-0.21, P = 0.03; R2 = 0.22), although mediators did not significantly differ in strength (ß = 0.08, 95% CI = -0.16 to 0.32; P = 0.49). Results provide novel evidence for the role of pain catastrophizing and limiting behaviors in explaining the association between anxiety and postconcussion symptoms. Addressing both factors may improve the recovery trajectory of individuals with mTBI. Emphasizing limiting behavior may yield more consistent and reliable effects. CONCLUSION: Results support developing interventions to directly target anxiety, for pain catastrophizing, and for activity engagement despite symptoms, to decrease symptom severity among patients with mTBI.

Communication impairment in Parkinson's disease: Impact of motor and cognitive symptoms on speech and language.

Communication impairment is common in Parkinson's disease (PD) and may have both motor speech control and cognitive-linguistic underpinnings. The neurobiology of communication impairment in PD is poorly understood, and work is needed to disentangle the relative contributions of motor and cognitive dysfunction. In clinical practice, cognitive-linguistic impairments are often overlooked despite the large body of research on this topic in neurocognitive and linguistics literature. In this review, we will discuss the roles of motor speech changes, cognitive and linguistic impairment, and other related functions in the communication disabilities of individuals with PD. We will describe the various types of communication difficulties in PD and tools for measuring these symptoms. We will discuss specific deficits that may further understanding of the neurobiology of communication impairment in PD, including voice and speech acoustic changes, linguistic processing and production difficulties, and pausing. We will emphasize the importance of an interdisciplinary approach and the patient perspective on daily communication in guiding future research.

Communication and quality of life outcomes from an interprofessional intensive, comprehensive, aphasia program (ICAP).

BACKGROUND: Intensive Comprehensive Aphasia Programs (ICAPs) have developed in response to a growing need for treatments which produce changes in language function in people with aphasia, especially in the chronic phase of recovery. ICAPs are growing in number and several papers have presented preliminary results of their use, but little data exist about their efficacy or effectiveness. OBJECTIVE: This paper explores the communication effects of an ICAP program that incorporated evidenced-based individual and group treatment in an interprofessional program. METHOD: Twenty-seven individuals with chronic aphasia were provided with 30 h of interprofessional treatment a week for a four-week period in both individual and group formats. A delayed treatment, within-participant research protocol was used. Language measures were taken at two intervals pre- and two intervals post treatment. Functional, narrative, and quality of life measures were taken once pre and once post treatment. RESULTS: Significant change was observed on targeted language functions post treatment. Significant treatment effects were also observed on functional and quality of life measures as well as on all impairment-based language measures for the group. CONCLUSION: The results provide evidence of linguistic and quality of life change in individuals with chronic aphasia who were treated in an interprofessional ICAP.

New levels of language processing complexity and organization revealed by granger causation.

Granger causation analysis of high spatiotemporal resolution reconstructions of brain activation offers a new window on the dynamic interactions between brain areas that support language processing. Premised on the observation that causes both precede and uniquely predict their effects, this approach provides an intuitive, model-free means of identifying directed causal interactions in the brain. It requires the analysis of all non-redundant potentially interacting signals, and has shown that even "early" processes such as speech perception involve interactions of many areas in a strikingly large network that extends well beyond traditional left hemisphere perisylvian cortex that play out over hundreds of milliseconds. In this paper we describe this technique and review several general findings that reframe the way we think about language processing and brain function in general. These include the extent and complexity of language processing networks, the central role of interactive processing dynamics, the role of processing hubs where the input from many distinct brain regions are integrated, and the degree to which task requirements and stimulus properties influence processing dynamics and inform our understanding of "language-specific" localized processes.

The role of animacy and thematic relationships in processing active English sentences: evidence from event-related potentials.

Recent event-related potential studies report a P600 effect to incongruous verbs preceded by semantically associated inanimate noun-phrase (NP) arguments, e.g., "eat" in "At breakfast the eggs would eat...". This P600 effect may reflect the processing cost incurred when semantic-thematic relationships between critical verbs and their preceding NP argument(s) bias towards different interpretations to those dictated by their sentences' syntactic structures. We have termed such violations of alternative thematic roles, 'thematic role violations.' Semantic-thematic relationships are influenced both by semantic associations and by more basic semantic features, such as a noun's animacy. This study determined whether a P600 effect can be evoked by verbs whose thematic structures are violated by their preceding inanimate NP arguments, even in the absence of close semantic-associative relationships with these arguments or their preceding contexts. ERPs were measured to verbs under four conditions: (1) non-violated ("At breakfast the boys would eat..."); (2) preceded by introductory clauses and animate NPs that violated their pragmatic expectations but not their thematic structures ("At breakfast the boys would plant..."); (3) preceded by semantically related contexts but inanimate NPs that violated their thematic structures ("At breakfast the eggs would eat..."); (4) preceded by semantically unrelated contexts and inanimate NPs that also violated their thematic structures ("At breakfast the eggs would plant..."). Pragmatically non-thematic role violated verbs preceded by unrelated contexts and animate NPs evoked robust N400 effects and small P600 effects. Thematically violated verbs preceded by inanimate argument NPs evoked robust P600 effects but no N400 effects, regardless of whether these inanimate arguments or their preceding contexts were semantically related or unrelated to these verbs. These findings suggest that semantic-thematic relations, related to animacy constraints on verbs' arguments, are computed online and can immediately impact verb processing within active, English sentences.

Making sense of discourse: an fMRI study of causal inferencing across sentences.

To build up coherence between sentences (comprehend discourse), we must draw inferences, i.e. activate and integrate information that is not actually stated. We used event-related fMRI to determine the localization and extent of brain activity mediating causal inferencing across short, three-sentence scenarios. Participants read and made causal coherence judgments to sentences that were highly causally related, intermediately related or unrelated to their preceding two-sentence contexts. The highly related and intermediately related scenarios were matched in terms of semantic similarities between their individual component words. A pre-rating study established that causal inferences were generated to the intermediately related but not to the highly related or unrelated scenarios. In the scanner, sentences that were intermediately related (relative to highly related or unrelated) to their preceding contexts were associated with longer judgment reaction times and sustained increases in hemodynamic activity within left lateral temporal/inferior parietal/prefrontal cortices, the right inferior prefrontal gyrus and bilateral superior medial prefrontal cortices. In contrast, sentences that were unrelated (relative to highly related) to their preceding contexts were associated with only transient increases in activity (at, but not after, the peak of the hemodynamic response) within the right lateral temporal cortex and the right inferior prefrontal gyrus. These data suggest that, to make sense of discourse, we activate a large bilateral cortical network in response to what is not explicitly stated. We suggest that this network reflects the activation, retrieval and integration of information from long-term semantic memory into incoming discourse structure during causal inferencing.