ABSTRACT
Few reports have yet investigated adequate cognitive rehabilitation for patients with chronic cognitive disorder. In this report, we describe a case of cognitive rehabilitation 10 months after onset of cerebral infarction in the right middle cerebral artery region, resulting in a good outcome. The patient was a 44-year-old right-handed male, with primary symptoms of inattention and left hemispatial neglect. The patient had not undergone any neuropsychological evaluations or cognitive rehabilitation until 10 months after disease onset. After 30 days of both direct attention training and metacognitive strategy training, including time pressure management, improvement of his cognitive disorder was achieved. The teaching of internal methods to improve metacognition with a high level of evidence was effective even 10 months after onset. Furthermore, it is important for therapists who provide cognitive rehabilitation using metacognitive strategy training to understand patients' remaining functions based on neuropsychological assessment, and to consider and teach compensatory methods so that they can be effectively used by patients in situations of daily life.
ABSTRACT
We report a case of a 67-year-old man with left thalamic hemorrhage. He had right hemiplegia, aphasia, and higher brain dysfunction. The hemiplegia and aphasia improved with rehabilitation treatment；however, he was unable to perform activities of daily living. Visual and tactile agnosia was suspected using the visual perception test for agnosia 1 month after the hemorrhage. The patient was able to recognize common objects, such as chopsticks and a shaver, by labeling them with their names because he could read words. He was able to use these objects as a result. Multimodal agnosia with combined visual-tactile agnosia usually occurs as lesions in and around the left lateral occipital complex where the ventral stream of somatosensory information processing merges with that of visual information processing. Concurrently, the present case seems very unusual because multimodal agnosia was likely to have occurred as a lesion of the left thalamus. The compensatory strategy to put objects into words was effective in this case. We repeatedly assessed and analyzed his higher brain dysfunction in detail, which led to effective rehabilitation treatment. The present case highlights the importance of planning an appropriate treatment based on detailed evaluation and accurate diagnosis of the higher brain dysfunction in patients with neurological deficits.
ABSTRACT
We report a case of a 67-year-old man with left thalamic hemorrhage. He had right hemiplegia, aphasia, and higher brain dysfunction. The hemiplegia and aphasia improved with rehabilitation treatment；however, he was unable to perform activities of daily living. Visual and tactile agnosia was suspected using the visual perception test for agnosia 1 month after the hemorrhage. The patient was able to recognize common objects, such as chopsticks and a shaver, by labeling them with their names because he could read words. He was able to use these objects as a result. Multimodal agnosia with combined visual-tactile agnosia usually occurs as lesions in and around the left lateral occipital complex where the ventral stream of somatosensory information processing merges with that of visual information processing. Concurrently, the present case seems very unusual because multimodal agnosia was likely to have occurred as a lesion of the left thalamus. The compensatory strategy to put objects into words was effective in this case. We repeatedly assessed and analyzed his higher brain dysfunction in detail, which led to effective rehabilitation treatment. The present case highlights the importance of planning an appropriate treatment based on detailed evaluation and accurate diagnosis of the higher brain dysfunction in patients with neurological deficits.
ABSTRACT
Few reports have yet investigated adequate cognitive rehabilitation for patients with chronic cognitive disorder. In this report, we describe a case of cognitive rehabilitation 10 months after onset of cerebral infarction in the right middle cerebral artery region, resulting in a good outcome. The patient was a 44-year-old right-handed male, with primary symptoms of inattention and left hemispatial neglect. The patient had not undergone any neuropsychological evaluations or cognitive rehabilitation until 10 months after disease onset. After 30 days of both direct attention training and metacognitive strategy training, including time pressure management, improvement of his cognitive disorder was achieved. The teaching of internal methods to improve metacognition with a high level of evidence was effective even 10 months after onset. Furthermore, it is important for therapists who provide cognitive rehabilitation using metacognitive strategy training to understand patients' remaining functions based on neuropsychological assessment, and to consider and teach compensatory methods so that they can be effectively used by patients in situations of daily life.
ABSTRACT
Objective：It is often difficult to provide effective functional training in patients with severe attention deficit caused by organic damage to the brain. Herein, we report a case of attention deficit in a patient with subarachnoid hemorrhage, which was successfully treated by virtual reality (VR)-guided rehabilitation.Methods：A 71-year-old woman was transferred to our hospital for rehabilitation after a subarachnoid hemorrhage. The patient suffered from severe attention deficit. She was unable to follow instructions from therapists and was unable to concentrate on rehabilitation tasks. We attempted VR-guided rehabilitation using mediVR KAGURA (mediVR, Toyonaka, Japan) in order to improve her attention deficit. The training was performed approximately 20 min every weekday, for 4 months in a 360-degree VR environment, with no background image initially. The difficulties in physical and cognitive tasks were adjusted by focusing on the size, range of appearance, and falling speed of each task object, so that even patients with severe attention deficit could respond to these tasks appropriately.Results：After the above-mentioned VR-guided training, the trail making test A, behavioral inattention test, and moss attention rating scale were improved from 300 s (could not complete the test）to 100 s, 119 to 133, and 55 to 98, respectively. In addition, in the clinical assessment for attention, the time required for visual obliteration tests was significantly shortened, and clinical symptoms associated with attention deficit were also improved clinically.Conclusion：VR-guided rehabilitation has the potential to be used as a new therapeutic approach to improve attention deficit.
ABSTRACT
Fat embolism syndrome (FES) is a serious complication of orthopedic surgery. We describe a woman in her 30s, who experienced cerebral FES after extensive femoral tumor resection and intercalary endoprosthesis for a malignant soft tissue tumor of the thigh. Before the surgery, the patient was able to walk with a single axillary crutch, capable of independent self-care and had no cognitive problems. After the surgery, the patient developed respiratory and central nervous system symptoms, which are characteristic of FES. After critical care, we provided rehabilitation treatment, which included getting out of bed, basic motion training, cognitive rehabilitation treatment, and Activity of Daily Living (ADL) training. At the time of commencement of the rehabilitation treatment, the patient presented with higher brain dysfunctions, such as cognitive dysfunction (Mini Mental State Examination：MMSE score 21 points), attentional dysfunction and left unilateral spatial neglect (USN). However, apparent motor paralysis of the extremities was not detected. On the 95th day after the surgery, the patient's MMSE score was 29 points, and the attentional dysfunction and USN were resolved. Additionally, the patient was again able to walk with axillary crutch. Six months after the surgery, the patient could walk independently without the aid of a crutch. One year after the surgery, the patient's reinstated to work. Cerebral FES may be accompanied with higher brain dysfunction；present a variety of higher brain dysfunctions；however, the symptoms may be reversible and resolved with rehabilitation treatment.
ABSTRACT
Since foreign patients may have inadequate Japanese language proficiency, rehabilitation techniques and evaluations of the higher brain and language function are often challenging. Here, we report a Hongkongese patient who suffered from higher brain dysfunction and dysgraphia after brain surgery. The patient was a 29-year-old left-handed man admitted to the Osaka International Cancer Institute for surgical resection of a choroid plexus tumor located on the trigone in the right lateral ventricle. Since the patient's mastery of the Japanese language was poor on preoperative evaluation, we partially evaluated his higher brain functions in Cantonese and English. However, he experienced left hemispatial neglect and spatial dysgraphia on postoperative day (POD) 2. On POD 48, his spatial dysgraphia (mainly in Cantonese) and higher brain functions improved with rehabilitation treatment, which involved verbal and non-verbal techniques such as task presentation and pointing. Although rehabilitation tasks and techniques are difficult due to language barriers, non-verbal techniques can be effective in providing treatment. Furthermore, it is important to evaluate the patient's language proficiency on preoperative assessment, especially in non-native Japanese speakers.
ABSTRACT
Objective：It is often difficult to provide effective functional training in patients with severe attention deficit caused by organic damage to the brain. Herein, we report a case of attention deficit in a patient with subarachnoid hemorrhage, which was successfully treated by virtual reality (VR)-guided rehabilitation.Methods：A 71-year-old woman was transferred to our hospital for rehabilitation after a subarachnoid hemorrhage. The patient suffered from severe attention deficit. She was unable to follow instructions from therapists and was unable to concentrate on rehabilitation tasks. We attempted VR-guided rehabilitation using mediVR KAGURA (mediVR, Toyonaka, Japan) in order to improve her attention deficit. The training was performed approximately 20 min every weekday, for 4 months in a 360-degree VR environment, with no background image initially. The difficulties in physical and cognitive tasks were adjusted by focusing on the size, range of appearance, and falling speed of each task object, so that even patients with severe attention deficit could respond to these tasks appropriately.Results：After the above-mentioned VR-guided training, the trail making test A, behavioral inattention test, and moss attention rating scale were improved from 300 s (could not complete the test) to 100 s, 119 to 133, and 55 to 98, respectively. In addition, in the clinical assessment for attention, the time required for visual obliteration tests was significantly shortened, and clinical symptoms associated with attention deficit were also improved clinically.Conclusion：VR-guided rehabilitation has the potential to be used as a new therapeutic approach to improve attention deficit.
ABSTRACT
Fat embolism syndrome (FES) is a serious complication of orthopedic surgery. We describe a woman in her 30s, who experienced cerebral FES after extensive femoral tumor resection and intercalary endoprosthesis for a malignant soft tissue tumor of the thigh. Before the surgery, the patient was able to walk with a single axillary crutch, capable of independent self-care and had no cognitive problems. After the surgery, the patient developed respiratory and central nervous system symptoms, which are characteristic of FES. After critical care, we provided rehabilitation treatment, which included getting out of bed, basic motion training, cognitive rehabilitation treatment, and Activity of Daily Living (ADL) training. At the time of commencement of the rehabilitation treatment, the patient presented with higher brain dysfunctions, such as cognitive dysfunction (Mini Mental State Examination：MMSE score 21 points), attentional dysfunction and left unilateral spatial neglect (USN). However, apparent motor paralysis of the extremities was not detected. On the 95th day after the surgery, the patient’s MMSE score was 29 points, and the attentional dysfunction and USN were resolved. Additionally, the patient was again able to walk with axillary crutch. Six months after the surgery, the patient could walk independently without the aid of a crutch. One year after the surgery, the patient’s reinstated to work. Cerebral FES may be accompanied with higher brain dysfunction；present a variety of higher brain dysfunctions；however, the symptoms may be reversible and resolved with rehabilitation treatment.
ABSTRACT
Objective：To investigate the living conditions of patients who had experienced childhood onset of higher brain dysfunction and determine their problems with respect to diagnosis, school re-enrollment, and employment.Subjects and Methods：A retrospective investigation was performed in 196 subjects (122 men and 74 women) enrolled in the seven supporting centers in Japan for patients with higher brain dysfunction who were injured (or developed primary diseases) and diagnosed with higher brain dysfunction under 18 years old, and were not older than 40 at the time of investigation.Results：Primary diseases included traumatic brain injury (109 patients), cerebrovascular disease (35), encephalitis/encephalopathy (27), brain tumor (17), and brain hypoxia (8). Forty-two patients (21％) were diagnosed with higher brain dysfunction ≥1 year after brain damage and 64 (33％) started receiving support ≥1 year after brain damage. Of those who were re-enrolled in schools, 6％ left high schools and 17％ left colleges before graduation, mainly because of maladjustment to school life. Thirty-three (47.8％) among 69 patients who were ≥20 years were employed at the time of investigation, and 19％ were living on remuneration alone.Conclusion：To resolve problems in patients with childhood-onset higher brain dysfunction, it is necessary to establish early diagnosis as well as collaboration systems among medical, educational, and welfare institutions to support these patients.
ABSTRACT
Objective：To investigate the living conditions of patients who had experienced childhood onset of higher brain dysfunction and determine their problems with respect to diagnosis, school re-enrollment, and employment.Subjects and Methods：A retrospective investigation was performed in 196 subjects (122 men and 74 women) enrolled in the seven supporting centers in Japan for patients with higher brain dysfunction who were injured (or developed primary diseases) and diagnosed with higher brain dysfunction under 18 years old, and were not older than 40 at the time of investigation.Results：Primary diseases included traumatic brain injury (109 patients), cerebrovascular disease (35), encephalitis/encephalopathy (27), brain tumor (17), and brain hypoxia (8). Forty-two patients (21％) were diagnosed with higher brain dysfunction ≥1 year after brain damage and 64 (33％) started receiving support ≥1 year after brain damage. Of those who were re-enrolled in schools, 6％ left high schools and 17％ left colleges before graduation, mainly because of maladjustment to school life. Thirty-three (47.8％) among 69 patients who were ≥20 years were employed at the time of investigation, and 19％ were living on remuneration alone.Conclusion：To resolve problems in patients with childhood-onset higher brain dysfunction, it is necessary to establish early diagnosis as well as collaboration systems among medical, educational, and welfare institutions to support these patients.
ABSTRACT
We report five cases of anti-<i>N</i>-methyl-D-aspartate receptor (NMDAR) encephalitis. Five women (27-38 years), Who-presented with psychiatric symptoms, neurological complications, and decreased consciousness, were diagnosed with anti-NMDAR encephalitis after testing positive for serum anti-NMDAR antibodies. The mean（±SD）for hospitalization duration was 272.4（±144.8)days. All patients presented with respiratory failure due to central hypoventilation and required mechanical ventilation for 50.2（±13.1）days on average. Four patients showed no abnormal findings upon brain MRI, one showed high intensity lesions in the right temporal cortex and bilaterally in the hippocampus on T2 weighted images. Higher brain function assessment revealed an overall decrease in intelligence, attention, memory, and executive function in all patients. Temporal assessments revealed progressive improvement in these dysfunctions over several years. Four patients presented with deep venous thrombosis, articular contracture, ectopic ossification, and compression paralysis during the first immobility episode. Two had severely impaired communication and ability to perform activities of daily living when admitted for rehabilitation. However, eventually all the patients attained a premorbid state.<br> Anti-NMDAR encephalitis possibly results from reversible synaptic dysfunction；therefore, it has a better functional prognosis compared with classical limbic encephalitis and other paraneoplastic neurologic syndromes. Previous studies found abnormalities in the limbic area on MRI in about 25％ of patients, although other findings were non-specific. Prevention of disuse syndrome due to prolonged immobility is important in acute phase rehabilitation. Our study shows that long-term temporal assessments of higher brain function are necessary and useful in the chronic stage.
ABSTRACT
A 43-year-old man was admitted to our hospital for rehabilitation of higher brain dysfunction caused by traumatic brain injury. He had undergone an emergency operation for acute epidural hematoma after a fall. He had impaired cognitive function with regard to memory, attention, and executive function. However, he also exhibited facial features such as frontal baldness and hatched face. Neurological examination showed mild distal muscle weakness in the extremities, gait disturbance, and grip and percussion myotonia. Needle electromyography showed myotonic discharges. Brain magnetic resonance imaging did not show any intra-axial abnormalities. Myotonic dystrophy (DM) was therefore diagnosed. Rehabilitation resulted in improved gait stability, but the patient's cognitive function did not improve. Severity of illness in DM patients varies from a floppy infant to a lack of awareness of the disease throughout one's lifetime. Therefore, DM patients might not be properly diagnosed because of the mildness of their clinical symptoms. It is important for non-neurologists to be aware of the possible occurrence of this disease.
ABSTRACT
To prevent individuals with traumatic brain injury (TBI) from becoming socially isolated, various forms of group training have been tried. We have implemented group training for chronic-phase TBI in the form of psychiatric day care. In this study, we examined the effectiveness of day care based group training for 20 cases. The results of a caregiver questionnaire after 6 months training indicated that significant improvement was noted in both psychological aspects (in terms of depressive moods and excitement) and in behavioral aspects (understanding of others' feelings and personal appearance). This group training system might improve patients' motivation and communicative ability. These results suggested that day care based group training for TBI was effective in both psychological and behavioral aspects.
ABSTRACT
Small group training, that is “A rehabilitation class to prepare patients for their return to society,” was created for 5 patients with higher brain dysfunction who had not yet returned to normal daily life after undergoing individual cognitive training, in order to provide them with a better insight into their disease, and to improve their communication abilities and interpersonal skills. The class consisted of 10 sessions (each session lasting 2 hours and 30 minutes) over a 4-month period, which consisted of an opening address, a short lecture, social skills training, tea time, and recreation. Before and after the class, the patients and their families were asked to complete the Dysexecutive Questionnaire, and any decrease in the difference in the scores between the patients and families suggested that the class had enhanced the patients' self awareness. The Baum test showed the patients having an increased interest in the outside world and a tendency to also have more internal energy. The Clinical Global Impression, as evaluated by the patients' families, indicated an improvement in all patients. We therefore consider this rehabilitation class to help prepare patients for their return to society to be useful as one step to encourage an increased social participation in patients suffering from a higher brain dysfunction.
ABSTRACT
The purpose of this study was to estimate the effect of our post-acute comprehensive intensive inpatient treatment (Program A) on persons with acquired brain injury in the hospital. Program A, designed for work or school, consists of daily six hours sessions for three months, personal and group sessions, and family support. It was designed to build cognitive and behavioral skills through a transdisciplinary approach and 17 patients with acquired brain injury were enrolled in the program. Seventeen program non-participants were selected as our control. Cognitive functions were measured with FIM, WAIS-III, RBMT, and TMT before and after the program. Significant cognitive improvements (especially attention) and increased societal participation were obtained for the Program A participants compared with non-participants. Considering that Program A improved both the cognitive function and level of social participation in program participants, we suggest that it is valuable to perform intensive treatment programs in an inpatient condition for acquired brain injury patients.
ABSTRACT
Higher brain dysfunction generally refers to cognitive and/or behavioral changes resulting from stroke, traumatic head injury, hypoxic encephalopathy, or any other of a number of cerebrovascular events. In 2004, the Ministry of Health, Labour and Welfare of Japan released a provisional figure of the probable prevalence of higher brain dysfunction in Japan as some 300,000 individuals. The aim of this study was to provide an estimate of the number of people with higher brain dysfunction in Tokyo. All 651 hospitals in Tokyo were surveyed between January 7, 2008 and January 20, 2008 by questionnaire. Analysis of the data showed 118 incidents of brain damage which resulted in higher brain dysfunction. This roughly converts to 3,010 incidents per year in Tokyo. Taking life expectancy into consideration, we estimate the current number of higher brain dysfunction survivors to be 49,508 (male : 33,936, female : 15,572) in Tokyo. The social impact of higher brain dysfunction has recently emerged amid growing recognition that disturbances of attention, memory, and behavior overshadow the contribution of focal motor deficits to chronic dependency. Our data provide information about the number of people that may require appropriate provision in the community.
ABSTRACT
We estimated the severity of higher brain dysfunction according to the Ministry of Health, Labour and Welfare classification for 113 patients with higher brain dysfunction, and analyzed the correlation between severity and actual employment rate, based on neuropsychological findings and social behavioral disturbance. The actual job rate was similar to the theoretical one, which was determined by the Ministry's severity classification and was then correlated with the patient's neuropsychological findings (WAIS-R, RBMT, TMT-B and social cognition). In patients with a similar degree of severity, these neuropsychological findings did not affect their employment or unemployment. Our study demonstrated that the theoretical employment rate determined using the Ministry's classification was similar to the real one, and suggested that non-personal factors were responsible for the differences in employment rates in patients with the same severity of dysfunction.
ABSTRACT
Clinical rehabilitation in patients after a cerebrovascular accident or a head injury is sometimes hampered by the onset of emotional disorders, particularly during the initial period of convalescence. Sodium valproate (VPA) is used not only as an antiepileptic drug but also as a mood stabilizer in clinical psychiatric practice. We used VPA for treating emotional disorders, thereby increasing the effectiveness of rehabilitation in a convalescent setting. We administered VPA to 7 patients with higher brain dysfunction to treat their emotional disorders from August 2006 to April 2007 in the convalescent rehabilitation ward (60 beds) of Yamaguchi Rehabilitation Hospital. We used the Japan Stroke Scale-Emotional Disturbance Scale (JSS-E) to evaluate the patient's mental condition and the Barthel Index (BI) to assess the effect of rehabilitation. The JSS-E scores showed significant improvement after VPA administration. The BI scores also showed improvement. These scores indicate that VPA was effective in treating emotional disturbances and in improving patient's activities of daily living. Thus, we showed that VPA can be useful in treating emotional disorders during convalescent rehabilitation.
ABSTRACT
Diffuse axonal injury (DAI) is identified as one of the most important causes of cognitive disorders in patients with traumatic brain injury. Radiologic recognition of DAI can help in understanding the clinical syndrome and in making treatment decisions. However, CT and conventional MRI are often normal or demonstrate lesions that are poorly related to the cognitive disorders present. Recently, diffusion tensor imaging (DTI) and fiber tractography (FT) have been shown to be useful in detecting various types of white matter damage. The aim of this study was to evaluate the feasibility of using DTI and FT to detect lesions in DAI patients, and to correlate these DAI lesions with the patients' cognitive disorders. We investigated 9 normal volunteers and 9 patients with DAI. The DAI patients had impaired intelligence, as well as attention, memory and executive function disorders that restricted their activities of daily living. In the DAI patients, DTI showed abnormal brain areas in the corpus callosum, fornix, frontal and parietal lobe white matter, and FT revealed interruptions of the white matter fibers in the corpus callosum and the fornix when compared with the normal volunteers, while no lesions were found on conventional MRI. DTI and FT can directly visualize DAI lesions, which cannot be reliably detected by conventional methods. Accordingly, both DTI and FT may be useful techniques for the evaluation of DAI, and may have the potential to be applied to planning rehabilitation therapy, and predicting the neurologic prognosis in DAI patients with cognitive disorders.