Pain in Canadian Long-Term Care Homes: A Call for Action.

Navigating the evaluation and management of pain in long-term care homes is a complex task. Despite an extensive body of literature advocating for a paradigm shift in pain assessment and management within long-term care homes, much more remains to be done. The assessment of pain in long-term care is particularly challenging, given that a substantial proportion of residents live with some degree of cognitive impairment. Individuals living with dementia may encounter difficulties articulating the frequency and intensity of their pain, potentially resulting in an underestimation of their pain. In Canada and in the United States, the interRAI Minimum Data Set 2.0, Minimum Data Set 3.0, and the interRAI Long-Term Care Facilities assessments are administered to capture the presence and intensity of pain. These assessment instruments are used both on admission and quarterly, offering a reliable and validated method for comprehensive assessment. Nonetheless, the daily assessment and documentation of pain across long-term care homes, which is used to inform the interRAI Pain Scale, is not always consistent. The reality is that assessing pain can be inaccurate for several reasons, including the fact that it is rated by long-term care staff with diverse levels of expertise, resources, and education. This call for action explores the current approaches used in pain assessment and management within long-term care homes. The authors not only bring attention to the existing challenges but also emphasize the necessity of considering a more comprehensive assessment approach.

Assessing neglect dyslexia with compound words.

OBJECTIVE: The neglect syndrome is frequently associated with neglect dyslexia (ND), which is characterized by omissions or misread initial letters of single words. ND is usually assessed with standardized reading texts in clinical settings. However, particularly in the chronic phase of ND, patients often report reading deficits in everyday situations but show (nearly) normal performances in test situations that are commonly well-structured. To date, sensitive and standardized tests to assess the severity and characteristics of ND are lacking, although reading is of high relevance for daily life and vocational settings. METHOD: Several studies found modulating effects of different word features on ND. We combined those features in a novel test to enhance test sensitivity in the assessment of ND. Low-frequency words of different length that contain residual pronounceable words when the initial letter strings are neglected were selected. We compared these words in a group of 12 ND-patients suffering from right-hemispheric first-ever stroke with word stimuli containing no existing residual words. Finally, we tested whether the serially presented words are more sensitive for the diagnosis of ND than text reading. RESULTS: The severity of ND was modulated strongly by the ND-test words and error frequencies in single word reading of ND words were on average more than 10 times higher than in a standardized text reading test (19.8% vs. 1.8%). CONCLUSION: The novel ND-test maximizes the frequency of specific ND-errors and is therefore more sensitive for the assessment of ND than conventional text reading tasks. (PsycINFO Database Record

Perceptual Relearning of Binocular Fusion and Stereoacuity After Brain Injury.

BACKGROUND: Brain lesions may disturb binocular fusion and stereopsis, leading to blurred vision, diplopia, and reduced binocular depth perception for which no evaluated treatment is currently available. Objective The study evaluated the effects of a novel binocular vision treatment designed to improve convergent fusional amplitude and stereoacuity in patients with stroke or traumatic brain injury (TBI). Methods Patients (20 in all: 11 with stroke, 9 with TBI) were tested in fusional convergence, stereoacuity, near/far visual acuity, accommodation, and subjective binocular reading time until diplopia emerged at 6 different time points. All participants were treated in a single subject baseline design, with 3 baseline assessments before treatment (pretherapy), an assessment immediately after a 6-week treatment period (posttherapy), and 2 follow-up tests 3 and 6 months after treatment. Patients received a novel fusion and dichoptic training using 3 different devices to slowly increase fusional and disparity angles. Results At pretherapy, the stroke and TBI groups showed severe impairments in convergent fusional range, stereoacuity, subjective reading duration, and partially in accommodation (only TBI group). After treatment, both groups showed considerable improvements in all these variables as well as slightly increased near visual acuity. No significant changes were observed during the pretherapy and follow-up periods, ruling out spontaneous recovery and demonstrating long-term stability of binocular treatment effects. Conclusions This proof-of-principle study indicates a substantial treatment-induced plasticity of the lesioned brain in the relearning of binocular fusion and stereovision, thus providing new, effective rehabilitation strategies to treat binocular vision deficits resulting from permanent visual cortical damage.

Perceptual relearning of binocular fusion after hypoxic brain damage: four controlled single-case treatment studies.

OBJECTIVE: Hypoxic brain damage is characterized by widespread, diffuse-disseminated brain lesions, which may cause severe disturbances in binocular vision, leading to diplopia and loss of stereopsis, for which no evaluated treatment is currently available. The study evaluated the effects of a novel binocular vision treatment designed to improve binocular fusion and stereopsis as well as to reduce diplopia in patients with cerebral hypoxia. METHOD: Four patients with severely reduced convergent fusion, stereopsis, and reading duration due to hypoxic brain damage were treated in a single-subject baseline design, with three baseline assessments before treatment to control for spontaneous recovery (pretherapy), an assessment immediately after a treatment period of 6 weeks (posttherapy), and two follow-up tests 3 and 6 months after treatment to assess stability of improvements. Patients received a novel fusion and dichoptic training using 3 different devices designed to slowly increase fusional and disparity angle. RESULTS: After the treatment, all 4 patients improved significantly in binocular fusion, subjective reading duration until diplopia emerged, and 2 of 4 patients improved significantly in local stereopsis. No significant changes were observed during the pretherapy baseline period and the follow-up period, thus ruling out spontaneous recovery and demonstrating long-term stability of treatment effects. CONCLUSIONS: This proof-of-principle study indicates a substantial treatment-induced plasticity after hypoxia in the relearning of binocular vision and offers a viable treatment option. Moreover, it provides new hope and direction for the development of effective rehabilitation strategies to treat neurovisual deficits resulting from hypoxic brain damage.

The frequency and significance of the word length effect in neglect dyslexia.

Neglect patients often omit or misread initial letters of single words, a phenomenon termed neglect dyslexia (ND). Omissions of whole words on the contralesional side of the page during paragraph reading are generally considered as egocentric or space-based errors, whereas misreading of the left part of a word can be viewed as a type of stimulus-centred or word-based, neglect-related error. The research of the last decades shed light on several effects of word features (such as written word frequency, grammatical class or concreteness) that modulate the severity of ND. Nevertheless, almost all studies about those modulating factors were case studies and some of them have not been replicated yet. Therefore, to date we do not know how relevant such effects of different word stimuli are for a population of ND patients. Knowing their incidence would improve our theoretical understanding of ND and promote the development of standardized ND assessments, which are lacking so far. In particular, case studies have shown that ND error frequency increases systematically with word length (word length effect, WLE) while other single case studies found contrary results. Hence, the existence of the WLE in ND is unsettled and its incidence and significance in stroke patients is unknown. To clarify this issue we evaluated the relation between word length and the extent (number) of neglected or substituted letters within single words in ND (neglect dyslexia extent, NDE) in a group of 19 consecutive ND patients with right hemisphere lesions. We found a clear WLE in 79% (15 of 19) of our ND patients, as indicated by significant correlations between word length and NDE. Concurrent visual field defects had no effect on the WLE in our sample, thus showing no influence of early visual cortical processing stages on the WLE in neglect dyslexia. In conclusion, our results suggest a clear relationship between word length and reading errors in ND and show that the WLE is a frequent phenomenon in ND.

Now You Feel both: Galvanic Vestibular Stimulation Induces Lasting Improvements in the Rehabilitation of Chronic Tactile Extinction.

Tactile extinction is frequent, debilitating, and often persistent after brain damage. Currently, there is no treatment available for this disorder. In two previous case studies we showed an influence of galvanic vestibular stimulation (GVS) on tactile extinction. Here, we evaluated in further patients the immediate and lasting effects of GVS on tactile extinction. GVS is known to induce polarity-specific changes in cerebral excitability in the vestibular cortices and adjacent cortical areas. Tactile extinction was examined with the Quality Extinction Test (QET) where subjects have to discriminate six different tactile fabrics in bilateral, double simultaneous stimulations on their dorsum of hands with identical or different tactile fabrics. Twelve patients with stable left-sided tactile extinction after unilateral right-hemisphere lesions were divided into two groups. The GVS group (N = 6) performed the QET under six different experimental conditions (two Baselines, Sham-GVS, left-cathodal/right-anodal GVS, right-cathodal/left-anodal GVS, and a Follow-up test). The second group of patients with left-sided extinction (N = 6) performed the QET six times repetitively, but without receiving GVS (control group). Both right-cathodal/left-anodal as well as left-cathodal/right-anodal GVS (mean: 0.7 mA) improved tactile identification of identical and different stimuli in the experimental group. These results show a generic effect of GVS on tactile extinction, but not in a polarity-specific way. These observed effects persisted at follow-up. Sham-GVS had no significant effect on extinction. In the control group, no significant improvements were seen in the QET after the six measurements of the QET, thus ruling out test repetition effects. In conclusion, GVS improved bodily awareness permanently for the contralesional body side in patients with tactile extinction and thus offers a novel treatment option for these patients.