Cognitive evaluation and rehabilitation in high- and low-income countries.

Starting from her own personal experience, in the First Part of the article, the author reconstructs how the specialized sectors of cognitive evaluation and rehabilitation evolved in Western countries (Europe, the United States, Canada, and Australia, in particular) during the second half of the last century and the first decades of this century. In the Second Part, she describes her personal experience in setting up a rehabilitation centre dedicated to traumatic brain-injured subjects and her commitment to international cooperation (Bolivia, Rwanda, Myanmar, Tanzania) in the field of cognitive evaluation and rehabilitation in favour of people with congenital and acquired cerebral pathology, especially in the paediatric age, since there is an almost total lack of diagnostic, but above all, rehabilitative procedures for cognitive functions in low-middle income countries. In the Third Part of the article, the author carries out an extensive review of the international literature on the differences in access to cognitive diagnostic evaluation and cognitive rehabilitation in middle- and low-income countries - but not only - underlining the urgent need to launch a major international collaborative effort to reduce and eliminate these discrepancies.

Progressive Unspecified Motor Speech Disorder: A Longitudinal Single Case Study of an Older Subject.

INTRODUCTION: In a few cases, neurodegenerative diseases debut with a speech disorder whose differential diagnosis can be difficult. CASE REPORT: We describe the case of a right-handed woman with a progressive speech impairment, which debuted when she was 80 years old. We report the results of neurological, neuropsychological, and imaging assessments with positron emission tomography (PET) over a period of nine years. Metabolic PET with 18F-FDG was performed at the age of 81 and repeated two years later due to the worsening of symptoms; amyloid PET with 18F-flutemetamol was performed at the age of 86. All PET results were quantitatively analyzed. A speech impairment remained the isolated neurological symptom for a long time, together with a mood disorder. Early FDG-PET showed hypometabolism in the left superior and inferior frontal areas, in the left superior temporal area, and in the right superior frontal area. Two years later, the hypometabolic area was more extensive. Amyloid PET was qualitatively and quantitatively normal. Nine years after the first symptoms, the speech production progressively worsened until complete anarthria, in association with writing impairment onset and signs of behavioral impairments. No signs of motor involvement were found. CONCLUSIONS: A progressive articulatory disorder without an evolution of motor disorders may be a distinct neurological degenerative entity, mainly affecting speech production for very a long time and with a specific early metabolic pattern in brain FDG-PET in the language production area. Monitoring patients with FDG-PET could predict the disease evolution years before a clinical deterioration.

Amnesia of Uncertain Etiology in an Adolescent during COVID-19 Pandemic: A Case Report.

Sudden retrograde memory loss, in the absence of neurological causes, is usually referred to as a dissociative symptom. Dissociative amnesia, defined in the DSM-V as an inability to remember important autobiographical experiences, usually of a traumatic or stressful nature, is however a controversial phenomenon. Few cases with this pattern are described in the scientific literature and still fewer regarding adolescents. The objective of this study was to describe the case of an unexplained sudden memory loss that only partially fits with the criteria for dissociative amnesia, in a juvenile patient aged 16 years, which occurred during the COVID-19 lockdown. After the exclusion of any organic disturbances, 10 days after the clinical onset, a series of psychometric (neuropsychological and psychodiagnostics) tests were administered to the patient. Recent distress associated with COVID-19 lockdown was reported, while no previous significant distress or psychiatric history emerged during the clinical interview, conducted with the patient and parents. Severe disturbances in remote memory tests were registered, while no impairments in cognitive or anterograde amnestic functions were found or personality disorders. The disturbance was diagnosed as "amnesia of uncertain etiology."

The Reliability of the Progression of Autonomies Scale Applied on Acquired Brain Injured Patients.

The Progression of Autonomies Scale (PAS) is a behavioral scale useful to assess the autonomy levels in acquired brain-injured patients. It provides a broad profile, assessing different domains of human activities ranging from personal, domestic, and extradomestic autonomies. This cross-sectional study is aimed at evaluating the reliability of this scale on a large cohort of acquired brain injury (ABI) patients. Fifty-one ABI patients (49% traumatic, 33.3% hemorrhagic, 17.7% other etiologies), hospitalized in the S. Anna Institute of Crotone, Italy (mean age male 46.08 ± 14.53 and mean age female patients 43.2 ± 11.3) were recruited. We found a high level of reliability of the scale, with a coefficient at the inter-rater agreement between substantial (0.61 ≤ k ≤ 0.8) and almost perfect (0.81 ≤ k ≤ 1), and almost perfect at the test-retest (intra-rater). We confirm that the PAS is a well-structured tool for the assessment of the autonomy levels in brain-injured patients. These findings encourage the application of this scale in the clinical practice of rehabilitation unit to design a tailored rehabilitation treatment on real goals and to monitor the generalization of the recovered abilities to the daily routine activities.

Cardio-respiratory autonomic responses to nociceptive stimuli in patients with disorders of consciousness.

The autonomic response to pain might discriminate among consciousness disorders. Therefore, aim of this study was to describe differences between minimally conscious state (MCS) and unresponsive wakefulness syndrome (UWS) patients in their autonomic response to a nociceptive stimulus. ECG, respiration, finger blood pressure (BP) and total peripheral resistances (TPR) were continuously recorded before, during and after a standardized noxious stimulus in 20 adult brain-injured patients, 14 in UWS and 6 in MCS. Occurrence of fast autonomic responses synchronous with the stimulus was detected by visual inspection of the tracings; short-term (<20 s) and long-term (between 20s and 50 s from the stimulus) responses were evaluated by beat-by-beat quantitative analysis. The noxious stimulus elicited fast responses in both groups, but only MCS patients showed a significant short-term response in TPR and long-term response in HR. Thus, short- and long-term cardiovascular responses to pain might integrate neuro-behavioural assessments to discriminate between MCS and UWS.

Long-term services for the care and rehabilitation of people with severe acquired brain injury: a multicentre, cross-sectional study of 536 Italian families.

BACKGROUND: People with severe acquired brain injuries (ABIs) require complex, long-term multidisciplinary healthcare, and social welfare programmes, and their families experience social and emotional consequences that profoundly condition their quality of life. OBJECTIVE: To investigate whether the possibility of gaining access to local rehabilitation and other services positively influences not only the quality of life of the patients but also the quality of life of their families. METHODS: The sample consisted of 536 families of patients with severe ABIs. They were administered a specific 50-item questionnaire with a mix of multiple choice answers, dichotomous (yes/no) answers, or answers based on a Likert-type scale. RESULTS: The results suggest that the long-term services provided to patients are substantially satisfactory but the data concerning the patients' social and working reintegration are discomforting. Furthermore, the families experience profound social discomfort related to their economic, emotional and caregiving burden regardless of the number and quality of the rehabilitation services activated, or the amount of welfare support received. CONCLUSIONS: Post-severe ABI services provided at a local level should include not only long-term rehabilitative and social support for the patients, but also long-term social and psychological support for their families.

Focal cerebral lesions and painting abilities.

Focal lesions such as strokes significantly affect painting production in the vast majority of artists. In particular, painters, when they resume painting, show changes in their painting style. In exceptional cases, there may be an apparent improvement in style, but in most cases, the changes represent nothing short of deterioration. This, however, varies according to the hemisphere affected. Painters with left-hemisphere lesions tend to show an inability to deal adequately with perspective and also tend to use simplified colors with fewer nuances. One often witnesses an evolution toward simpler, often "naïve" techniques, and at times rigid geometric repetitive features. Painters with right-hemisphere lesions also become unable to represent tridimensionality. In addition, their figures are often drawn in very summary fashion, with lack of coordination between volumes and space and a chromatic impoverishment; their main problem, however, is visuospatial, leading to neglect of the left side of the canvas.

Artistic creativity, artistic production, and aging.

This chapter reviews the changes produced by age on various aspects of artistic painting, particularly creativity and actual production. Aging in trained painters is often accompanied by a decline in creativity, which in turn is due to the cognitive decline related to aging. It has been argued, however, that aging does not cause a decline, but only changes in style and content. The two views are not mutually exclusive, and we present examples illustrating both aspects. We also show that, in addition to cognitive changes, impairment of sensory organs, especially vision, and of the bones and joints, may also produce marked changes in an artist's production and style. We conclude by showing that finding ways to induce creativity in persons who do not consider themselves artists can be a way of stimulating creativity and contribute to successful aging.

Evaluation of autonomies in the severely brain injured: the Progression of Autonomies Scale.

The aim of this study was to validate the Progression of Autonomies Scale (PAS) for the evaluation of autonomies in severe acquired brain injury patients. The PAS design is based on a model of progressive recovery of autonomies and is organized in three domains (Personal, Domestic and Extra-domestic). Scores assigned range from zero to three. The PAS items gather information about the patient's perception and awareness of his/her disability(ies) on admission and perception of his/her improvement at the end of a rehabilitation process. The PAS was administered to 127 inpatients on admission to and at discharge from a rehabilitation program. All 127 inpatients, recruited in a prospective multicenter study, completed the rehabilitation program. The statistical analysis identified a total of 38 items to be retained in the PAS, out of an initial 82 items. The results provide evidence of the validity and reliability of the PAS in its final version.

Circadian blood pressure and heart rate changes in patients in a persistent vegetative state after traumatic brain injury.

Alteration of autonomic nervous system regulation is known to be present in the persistent vegetative state after traumatic brain injury, termed the dysautonomic syndrome. This study assessed the circadian blood pressure and heart rate pattern and variability in the persistent vegetative state through noninvasive 24-hour ambulatory blood pressure monitoring. The study was performed in 20 subjects: 10 patients (six men and four women; mean age, 29.5+/-9.9 years; range, 19-39 years) in a vegetative state (mean, 27.3+/-5.6 days after trauma) and 10 healthy subjects as controls (six men and four women; mean age, 28+/-5.7 years; range, 29-37 years). The patients showed a blood pressure nondipper pattern; 24-hour, daytime, and nighttime values of blood pressure and heart rate were significantly higher in patients than in controls. The day-night difference in heart rate and blood pressure was also significantly lower in patients. Finally, SD and variation coefficients were significantly lower in patients. The results show changes in the variability and circadian blood pressure and heart rate patterns in persistent vegetative state patients with dysautonomic syndrome, as an expression of the sympathetic-parasympathetic activity imbalance in the control of vasomotor tone.

Preserved painting abilities after a stroke. The case of Paul-Elie Gernez.

In a famous paper published in 1948, the French neurologist Théophile Alajouanine discussed the influence of aphasia on artistic output. He used as examples three artists he had personally examined. They were the musician Maurice Ravel, the writer Valery Larbaud, and a painter whose name was not mentioned. We have now discovered the identity of this painter and therefore present, for the first time, with the permission of his family, an analysis of the works of Paul-Elie Gernez (1888-1948) before and after his cerebral stroke. This painter's ability to produce works of art was not really diminished by his aphasia. However, we do believe that there was a change in his style, which seemed to become less poetic, as though his ability to "invent" had decreased and he had lost some of his spontaneity. This and other published cases strongly suggest that in some artists the effect of cerebral lesions is different from that found in individuals with no artistic training. This difference may be attributable to the presence, in the former, of an expanded cortical representation, secondary to their lifelong formal training.

Locked-in syndrome: improvement in the prognosis after an early intensive multidisciplinary rehabilitation.

OBJECTIVE: To evaluate prognosis and recovery in patients with locked-in syndrome (LIS) receiving early intensive rehabilitative care. DESIGN: Consecutive sample and follow-up for 5 months to 6 years. SETTING: Three rehabilitation centers in Italy. PARTICIPANTS: Fourteen patients with LIS who underwent the same treatment and subsequently recovered. INTERVENTIONS: Intensive nursing care and intensive and early rehabilitative program, including physiotherapy and respiratory, swallowing, and speech training. For 4 patients, occupational therapy was performed; 4 subjects also had oculomotor training. After discharge, rehabilitative maintenance care continued for each patient. MAIN OUTCOME MEASURES: Motor recovery according to the Patterson and Grabois classification, functional improvement, and mortality rate. RESULTS: A significant motor recovery was found in 21% of subjects, within 3 to 6 months of onset of the morbid event; complete swallow recovery in 42%; verbal communication in 28%; communication through devices in 42%; effective bladder and bowel control in 35%; and good breathing patterns in 50%. At follow-up, the mortality rate was 14% and only 2 complications were reported. CONCLUSIONS: Intensive and early rehabilitation, begun within about 1 month of the morbid event, improved the functional recovery and reduced the mortality rate, which, as reported in the literature, had been 60% about 10 years ago. Further studies are necessary to confirm these data.

Competitive re-employment after severe traumatic brain injury: clinical, cognitive and behavioural predictive variables.

PRIMARY OBJECTIVE: To contribute to the identification of relationships between the return to pre-trauma competitive activities at the final discharge from rehabilitation facilities, and neuroanatomical, neuropsychological and behavioural data collected at different phases of the recovery from a traumatic brain injury (TBI). METHODS AND PROCEDURES: Thirty-five severe TBI subjects were retrospectively selected from 228 consecutive admissions over a 3-year period, according to pre-morbid, clinical and demographic characteristics matching the established selection criteria, and submitted to comprehensive neurophysiological, intellectual, cognitive and behavioural examinations carried out at different stages of the recovery (acute, subacute and chronic phases). EXPERIMENTAL INTERVENTIONS: Barthel Activity of Daily Living (BADL) index, Wechsler Adult Intelligence Scale-Revised (WAIS-R), checklists aimed to detect cognitive and behavioural dysfunction. MAIN OUTCOMES AND RESULTS: TBI subjects successfully re-employed obtained significantly better scores on length of coma and PTA, intellectual status, cognitive functioning and behavioural competence. Other specific measures of injury severity (CT-scan abnormalities, GCS score level, BADL index) resulted as being unrelated to the resumption of pre-trauma competitive activities. CONCLUSIONS: Findings seem to confirm the opinion that a significant relationship exists between the initial TBI severity level, especially as indicated by the duration of coma and PTA, and eventual return to work at the final discharge from facilities.