Neuropsychological outcome and community re-integration following traumatic brain injury: the impact of frontal and non-frontal lesions.

PRIMARY OBJECTIVE: To examine the relationship between cortical lesion location and brain injury outcome. It was hypothesized that focal frontal lesions after traumatic brain injury (TBI) would result in decreased executive and memory functioning and poor community participation outcome. RESEARCH DESIGN: Three quasi-experimental, prospective studies employed a total of 643 patients with focal frontal, fronto-temporal, non-frontal or no lesions in CT scans. METHODS AND PROCEDURES: CT scan analysis, neuropsychological assessment, the Neurobehavioural Functioning Inventory (NFI), the Community Integration Questionnaire (CIQ). MAIN RESULTS: In study 1, frontal and fronto-temporal groups performed worse in executive functioning and better in constructional ability. Study 2 found no differences in neuropsychological and community re-integration measures at 1-year follow-up. Study 3 found comparable neuropsychological test score improvement across groups over 1 year. CONCLUSIONS: Results are consistent with previous findings and document the potential for test score improvement with rehabilitation and suggest that lesion location needs to be considered when individual rehabilitation plans are being implemented in the post-acute stage of TBI.

Ecologic validity in neuropsychological assessment: prediction of wayfinding.

This study compared the ability of clinical and ecologic simulation measures to predict performance on environment-specific criterion measures of wayfinding. Thirty-one unilateral stroke participants comprised the right and left hemisphere groups (16 patients with left sided and 15 patients with right sided strokes). Participants completed a battery of clinical tasks (e.g., traditional paper-and-pencil measures of visualization, mental rotation, visual memory and spatial orientation), ecologic simulations (e.g., slide route recall and visualization of a model town from differing perspectives) and environment specific criterion tasks (e.g., route recall and directional orientation). The groups were equivalent in age, sex, education, handedness, and weeks since stroke. Both ecologic simulation tasks were found to have fairly good internal consistency and 1 simulation task was significantly related to real world wayfinding. Of the clinical tasks, 1 visual memory test was correlated with a directional orientation criterion task, but none correlated with route navigation ability. Results are consistent with literature purporting the benefits of ecologic simulation tasks as predictors of real world functioning.

Assessing risk and harm: the convergence of ethical and empirical considerations.

Neurorehabilitation clinicians are frequently asked to make clinical predictions of risk and harm in cases where persons with brain injury are believed to be unable or unsafe to conduct normal activities of daily living. Because predictions of risk and harm may ultimately limit a brain-injured person's autonomy, clinical decision makers should be aware of the ethical and empirical issues involved in such determinations. Constraining autonomy can be an ethical problem even when clinicians are apparently acting in patients' best interests. Clinicians must consider their ability to make accurate risk and harm predictions based on clinical data. Clinicians who are aware of contemporary ethical principles will be most prepared to integrate ethical and empirical considerations when determining risk and harm.

Repetitive transcranial magnetic stimulation does not replicate the Wada test.

The authors compared inferior frontal speech arrest from repetitive transcranial magnetic stimulation (rTMS) with bilateral Wada tests in 17 epilepsy surgery candidates. Although rTMS lateralization correlated with the Wada test in most subjects, rTMS also favored the right hemisphere at a rate significantly greater than the Wada test. Postoperative language deficits were more consistent with Wada results. Available methods for inducing speech arrest with rTMS do not replicate the results of Wada tests.

Short forms of the Benton Judgment of Line Orientation Test: development and psychometric properties.

The Benton Judgment of Line Orientation Test (BJLOT) is a widely used neuropsychological test measuring visuospatial judgment. The present study developed two 15-item short forms using data from 100 neurologic patients. The new short forms are equivalent in test construction and retain the stimulus properties of the original test. Correlational analyses revealed that each short form score related significantly to the original BJLOT (p <.001). The short forms were found to be internally consistent, with alpha reliability coefficients exceeding .82. Although kappa coefficient analyses found the short forms to lack sufficient accuracy in categorizing the cases via the BJLOT diagnostic classifications, the short forms were accurate in detecting the presence of impairment. These results suggest that the two short forms can be utilized as screening instruments for detecting the presence or absence of visuospatial impairment.

Word-type effects in word-stem priming: evidence for semantic processing in the perceptual representation system?

While a presemantic Perceptual Representation System is believed to mediate implicit memory tasks such as word-stem priming, clinical studies suggest semantic information can be processed during priming. To clarify the nature of this system, we investigated word-type effects in word-stem priming in a nonclinical sample of 41 undergraduates who rated the pleasantness of threatening and nonthreatening words, performed implicit and explicit memory tasks, and completed measures of mood state. More nonthreatening words were primed and scores on the Beck Depression Inventory were negatively correlated with production of nonthreatening words. During cued recall, more threatening than nonthreatening words were remembered and ratings of state anxiety were negatively correlated with recall of nonthreatening words. Our findings support the contention that semantic information is processed during priming and that mood congruent biases also operate. These results may call for a reconceptualization of the Perceptual Representation System.

Neuropharmacologic treatment of hemineglect: a case report comparing bromocriptine and methylphenidate.

Individuals who have hemineglect fail to attend to stimuli presented on the side of the body contralateral to a brain lesion. Although in animal studies the severity of neglect correlates with the degree of dopamine depletion, in hemineglect patients dopamine-enhancing medications have produced inconsistent results. We present a case of hemineglect following a right cerebrovascular accident in a 68-year-old man treated consecutively with methylphenidate and bromocriptine. Tests sensitive to neglect were administered during treatment with methylphenidate, then after all medications had been discontinued, then when the patient was taking low and moderate doses of bromocriptine, and again after all medications had been discontinued for 4 and 26 days. Methylphenidate was superior to no drug treatment. Bromocriptine produced more improvement in neglect than methylphenidate. Although the patient showed an exacerbation of his neglect after withdrawal from methylphenidate, performance gains persisted after withdrawal from bromocriptine. Treatment effects appear related to medication choice, timing of drug treatment, and the adaptability of dopaminergic receptor systems.

Word stem priming in unilateral stroke patients: word type and laterality effects.

We explored word type and lesion laterality effects in visual word stem completion priming. Participants were 24 stroke patients (12 left, 12 right) and 11 non-brain damaged, medical controls. Participants studied 32 threatening and 32 nonthreatening words and completed cued recall and word stem priming tasks (Mathews, Mogg, May, & Eysenck, 1989). Stroke groups had lower cued recall than controls and the right hemisphere damaged group was lower in cued recall than the left. Word type did not affect cued recall. Groups were comparable in word stem priming, and there was a word type effect such that more nonthreatening than threatening words were produced. No laterality effects were found in word stem priming. Implications for models of how words are processed during word stem priming are discussed.

Treatment of motor aprosodia with pitch biofeedback and expression modelling.

In motor aprosodia, imitation and production of emotional prosody and facial gestures are compromised. Despite the frequency with which aprosodia occurs after brain damage, and its potential to cause social and vocational disability, no formal treatments are available for this disorder. A case of motor aprosodia treated with voice pitch biofeedback and modelling of affective communication is presented. Utilizing the patient as her own control, the affective communication treatment was compared to traditional rehabilitation therapy. The results obtained suggest that affective communication treatment has potential in improving affective communication in brain-injured patients. Also notable was the fact that the improvements in emotional expression were stable over a 2-month follow-up period, and could not be attributed to recovery of function as a result of time passage, the effect of traditional rehabilitation, the effect of the extra attention paid to the patient, or examiner bias.

Food intake by brain-injured humans who are in the chronic phase of recovery.

This study examined whether survivors of traumatic brain injury differ from normal, non-injured controls in the regulation of food intake in their natural environment. Caregivers of 20 brain-injured subjects and 20 controls recorded in diaries: caloric intake, time of meals, subjective hunger ratings, and the number of persons present during meals for 7 consecutive days. Brain-injured subjects ate larger meals and more total (overall) calories per day compared with controls. In addition, the presence of other people during a meal, or social factor, was a significant predictor of meal size for the control subjects, but not for the brain-injured subjects. Brain-injured subjects also differed from control subjects in their response to pre-meal stomach content.

Self and observer predictions of memory performance in a brain-damaged sample.

The present study examined the ability of 23 brain-damaged patients and outside observers (i.e., close friends or relatives) to predict the patients' performance on standard clinical tests of memory. Several tests of verbal and nonverbal memory were specifically described in a questionnaire and subjects were asked to estimate upcoming performance. Individual subject factors were correlated with overall prediction accuracy and specific predictions were correlated with memory performance across each test. Individual differences, including memory ability, did not significantly influence the findings consistent with the view that memory and metamemory reflect independent variables. Although correlations obtained from the outside observers overall were higher and more often statistically significant, both patients and observers often made comparable predictions of the patients' task performance suggesting brain-damaged patients have some ability to make accurate self-assessments.

Transcortical motor aprosodia: functional and anatomical correlates.

Transcortical motor aprosodia (TMA), one of eight hypothesized disorders of affective communication, is characterized by impaired production of affective prosody and facial gestures, with intact imitation and comprehension of affect. It has been proposed that cortical TMA arises from lesions in the superior or anterior lateral surface of the right frontal lobe, but for various reasons it has not been possible to fully test this proposal. There have been few cases of TMA reported, and lesions have been too diffuse to permit accurate localization. A case is presented that meets both the functional and anatomical criteria proposed for cortical TMA, thus providing support for this system of classifying disorders of effective communication. Results suggest that the prosodic and gestural deficits in TMA may be dissociated, and that the gestural component extends to nonaffective facial movements.

Experience-dependent recovery of block design performance in male alcoholics: strategy training versus unstructured practice.

Neuropsychological functioning in alcoholics has been known to improve with length of abstinence. However, recovery in some areas is limited in the absence of specific cognitive stimulation. In order to better identify the factor(s) responsible for experience-dependent recovery in alcoholics, the current investigation compared a strategy training approach to the unstructured practice approach used in previous studies. Results showed that both treatments improved Block Design performance in abstinent male alcoholics to levels comparable to nonalcoholic controls, while unremediated alcoholics remained significantly impaired. Unstructured practice was sufficient to improve Block Design performance, with no additional advantage evident in alcoholics receiving strategy training. Hence, forced use of cognitive skills appears to be the important factor in experience-dependent recovery.

Methylphenidate in the treatment of aggression in two patients with antisocial personality disorder.

Two hospitalized patients with antisocial personality disorder (by DSM-III) and histories of childhood attention deficit disorder became less aggressive during trials of methylphenidate. The authors suggest a link between the childhood disorder and one subgroup of antisocial personality disorder.