The use of significant others to enhance the detection of malingerers from traumatically brain-injured patients.

Cognitive and neurobehavioral symptoms are common following traumatic brain injuries (TBIs). Because malingerers are likely to complain of such symptoms and perform poorly on neuropsychological tests, clinicians may have considerable difficulty distinguishing malingerers from TBI patients. In this study, we compared the subjective complaints of malingerers to TBI patients and then compared both groups to the problems observed by their respective significant others. We tested the assumption whether significant others could add one more piece to the challenging puzzle of diagnosing malingering. Our results demonstrated that the malingerers complained of more problems than patients who had sustained moderate or severe TBI. However, the significant others of the malingerers observed fewer cognitive, emotional-behavioral, and total problems than did the significant others of patients with severe, moderate, and even mild TBI. These findings suggest that the detection of malingering can be enhanced by interviews with significant others.

Are stroke patients discharged sooner if in-patient rehabilitation services are provided seven v six days per week?

A comparison was made of 113 consecutive patients who suffered a cerebrovascular accident and were hospitalized at a rehabilitation inpatient unit by dividing them into two groups: one group received the traditional 6-day/wk treatment regimen, and another group received treatment during the entire week (7 days/wk). When the patients were asked whether they had a preference (which did not affect their group assignment), 82% preferred a 6-day/wk program and 18% preferred a 7-day/wk program. The length of inpatient stay for the 57 patients enrolled in the 6-day/wk program was 20.14 days; for the 56 patients enrolled in the 7-day/wk program, the average length of stay was 20.11 days. This represents no significant difference. The functional recoveries were evaluated in areas that can affect length of stay, including dressing, bladder control, ambulation, and problem-solving. Both groups demonstrated significant gains in each domain when the intake and discharge ratings were compared. However, these gains were not significantly different when the 6- and 7-day/wk groups were compared. The results of the study contained herein, therefore, suggest that a 6-day/wk program for patients who have suffered a cardiovascular accident is just as effective as a 7-day/wk program.

Factorial validation of the Ruff-Light Trail Learning Test (RULIT).

The factorial validity of the Ruff-Light Trail Learning Test (RULIT) was evaluated for its specificity as a test of visuospatial learning and memory. In a sample of 307 normal adults, principal components analyses (PCAs) were calculated on scores from the RULIT and selected neuropsychological tests. The PCAs revealed visuospatial learning and memory components, which included RULIT scores that were empirically distinct from verbal learning and memory components. These results provide support for the RULIT as a measure of visuospatial learning and memory.

In search of a unified definition for mild traumatic brain injury.

Discrepant criteria are utilized by various disciplines for the diagnosis of mild traumatic brain injury (TBI). This study evaluates 76 patients, all of whom were diagnosed as having sustained a mild TBI according to the diagnostic criteria set forth by the American Congress of Rehabilitation Medicine (ACRM); yet only 34% of these patients were classified as having a concussion according to DSM-IV. A unified definition is proposed which is comprised of grades: Type I for ACRM, Type III for DSM-IV, and Type II to bridge the two discrepant definitions. An examination of the patients, subdivided into the three types, revealed no significant differences for (1) number of subjective complaints, (2) neurocognitive performances, and (3) pre-existing emotional risk factors. Thus, the proposed gradation unifies the definitions across the heterogeneity of mild TBI. However, further research is indicated for their clinical validation.

Are the subjective complaints of traumatically brain injured patients reliable?

The present study was designed to compare the subjective complaints of 50 traumatically brain injured (TBI) patients with the observations of their significant others. The complaints of the TBI patients and their significant others were contrasted according to the severity of the TBI and the type of complaint (physical, cognitive/behavioural and emotional). While no differences were found in physical complaints, the cognitive/behavioural and emotional complaints of TBI patients, regardless of the severity of the initial TBI, were significantly under-reported in comparison to the observations of their significant others. The data suggests that while this finding was most likely due to the TBI patients' poor awareness, it was unlikely to be the result of psychological denial since all of these individuals were evaluated in the context of being a plaintiff in personal injury litigation or a claimant in a Workers' Compensation claim. The data suggests that the cerebral trauma these patients sustained played a major role in their ability to recognize their cognitive, behavioural and emotional symptoms. Finally, the data suggests that clinicians should obtain information about the TBI patients' cognitive/behavioural and emotional functioning from their significant others, rather than rely entirely on the TBI patients' subjective assessment of these problems.

The psychological construct of word fluency.

Measures of word fluency have been convincingly linked in the literature to damage in the left prefrontal lobe region. Yet, a reduction in word fluency has also been reported with diffuse, multifocal and nonfrontal lobe damage. Despite the undisputed neuropsychological application of multiple word fluency measures, the psychological construct underlying this measure is not well understood. In a sample of 360 normal adults stratified by age, gender, and level of education, we found that auditory attention and word knowledge were among the most important determinants. With respect to memory, short-term memory was not significantly correlated, but long-term memory was. Despite these three determinants, a large share of the variance of the multiple regression was still not accounted for, which underscores the partial independence of word fluency per se. Thus, we propose a distinction between (1) poor word fluency secondary to deficient verbal attention, word knowledge, and/or verbal long-term memory and (2) impaired word fluency without these three areas concurrently affected. Based on a review of the literature, it seems likely that in the latter condition, the profile is more associated with prefrontal lobe impairment, versus in the former condition, diffuse multifocal or nonfrontal lobe factors can play a role.

Miserable minority: emotional risk factors that influence the outcome of a mild traumatic brain injury.

Emotional risk factors are explored in four case studies, each of whom had sustained a mild traumatic brain injury (MTBI). Selected pre-existing personality traits that compounded the symptom presentation included over-achievement, dependency, grandiosity and borderline personality traits. Premorbid risk factors are described and their influence on co-morbid and post-morbid difficulties is discussed. We also touched upon the therapeutic issues involved in our cases. General treatment considerations are highlighted for dealing with grandiosity, narcissistic features and borderline traits. Over-achievement and perfectionism are discussed in the context of providing treatment for stress management. Finally, the effect of pre-existing emotional trauma combined with the MTBI is discussed.

An attempt towards differentiating attentional deficits in traumatic brain injury.

Attentional deficits in patients suffering traumatic brain injury (TBI) can occur with minor to severe impact to the brain. Based on reviews of both the cognitive and neurobehavioral literature, the following three concepts of attention are addressed: (a) arousal/alertness, (b) selective attention, and (c) energetic aspects of attention, which include such components as effort, resource allocation, and speed of processing. Within each concept, definitions are proposed, the underlying brain mechanisms are identified, and the specific deficits associated with TBI are explored. This review combines theoretical perspectives and clinical findings with the objective of leading toward a diagnostic differentiation that in turn will benefit treatment planning.

Benton Controlled Oral Word Association Test: reliability and updated norms.

The aim of this paper is to update the over 20-year-old normative data for the Benton Controlled Word Association (COWA) Test. In a sample of 360 normal volunteers, the age ranged between 16-70 years, and the educational level ranged from 7-22 years. Care was taken to ensure that the population was heterogeneous, yet the two stratifications of gender, four age, and three educational groups led to 24 cells with 15 individuals in each. Test-retest reliability was established by testing 30% of the sample after a 6-month delay, which represents a typical follow up duration between testings in a clinical setting. The two forms of the COWA revealed significant test-retest reliability. Generally, our updated values fall above the original normative values, which were derived from a less well-educated and rural sample. No major gender or age trends were noted, but the COWA test performances were influenced by education, i.e., as the level of education increased, the performance on the COWA increased. The only gender differences that were found were for the women in the highest educational group ( > 16 years), who performed significantly better that men in the highest educational group. An error analysis of repetitions or perseverations is provided, with cut-off scores according to age levels. Finally, the updated COWA norms are compared to the original norms as well as to other measures of word fluency.

Estimation of premorbid functioning after traumatic brain injury.

Estimation of premorbid functioning in patients with traumatic brain injury (TBI) is a difficult but necessary step both in the assessment of neurological impairment and in planning treatment. Because the estimation process is almost always retrospective, its reliability is questionable. The use of multiple sources of information improves the likelihood of an accurate estimate. The effects of TBI cross a number of domains in the victim's life. Thus, premorbid functioning must be estimated in the physical, cognitive, emotional, social, financial and vocational spheres. Knowledge of baseline or premorbid functioning levels allows the clinician to appreciate the severity of injury, provide a prognosis, and shape treatment goals that are specific to the individual. In this article, we present the key questions to be addressed, suggest sources of information to obtain the answers, describe the processes through which answers should be obtained, and outline the uses for this important information in working with victims of TBI.

Selected cases of poor outcome following a minor brain trauma: comparing neuropsychological and positron emission tomography assessment.

Neuropsychological residua are common particularly in the early stages following a minor traumatic brain injury (TBI), however, a minority of individuals complain of persistent deficits following months or years post-accident. Nine such cases are presented with little or no evidence of brain damage demonstrated according to non-functional neuroimaging (for example CT, MRI), yet their neuropsychological examinations were positive. Since the introduction of positron emission tomography (PET), which captures a functional approach, the question arose as to what extent the two techniques (i.e. PET and neuropsychological examination) are interrelated. All nine minor TBI cases revealed a corroboration between the positive neuropsychological findings confirmed on the PET. The PET procedure documented neuropathology which frequently was pronounced in the frontal and anteriotemporo-frontal regions. Moreover, no significant differences were evident between those five cases with reported loss of consciousness vs. those four cases without.

What role does depression play on the performance of the Ruff 2 and 7 Selective Attention Test?

Depression is frequently a comorbid symptom in patients suffering from neurological or psychiatric illnesses, and this presents a challenge for the differential diagnosis of neuropsychological functioning, especially in the assessment of concentration. The 2 & 7 test was administered to 27 patients with major depression without other neurological or psychiatric illnesses. The average percentile rankings fell within the unimpaired range, with 42.7% for speed, 36.3% for accuracy, and 44.9% for processing. Only three patients were significantly slowed in performance speed, of whom two also showed deficient motor speed on eye-hand coordination performances. None demonstrated deficient accuracy rates, yet four patients were impaired in parallel processing. Thus, major depression did not for the majority of these patients impair 2 & 7 test performance, particularly if no concurrent motor slowing was present. Four guidelines for differential diagnosis are discussed.

Figural fluency: differential impairment in patients with left versus right frontal lobe lesions.

Based on an experimental study, Jones-Gotman and Milner demonstrated that patients with right frontal lobe lesions were impaired on design fluency. We sought a clinical adaptation and developed a psychometrically sound technique for design fluency. The present study explores the validity of the Ruff Figural Fluency Test (RFFT) in discriminating patients with either right frontal or nonright frontal lobe lesions. In the first of two studies, six subjects with circumscribed focal lesions were given the RFFT and the Jones-Gotman and Milner figural fluency task. In the second study, we identified a larger sample of 30 patients with focal lesions in the right frontal, left frontal, right posterior, or left posterior cortex. The results from both studies support the validity of the RFFT as a measure which is sensitive to right anterior dysfunction.

Preoperative versus postoperative neuropsychological sequelae of arteriovenous malformations.

In a cohort of 14 patients suffering from cerebral arteriovenous malformations (AVM), neuropsychological functioning was examined before and after AVM resection. Improvements after surgery were assumed to be due to enhanced neurocognitive functions associated with the hemisphere ipsilateral to the AVM, and to a lesser extent, with the contralateral hemisphere. Before surgical intervention, the performances of AVM patients were deficient relative to matched normals. Postoperatively, neuropsychological gains were observed particularly in the areas of learning, memory, and higher integrative thought, not only for ipsilateral, but also for contralateral functioning. Contralateral and ipsilateral improvement is consistent with the premise that cerebrovascular steal is lessened; thus, neurosurgical intervention to eliminate arteriovenous shunts was found to result in overall neurobehavioral gains.

Gender- and age-specific changes in motor speed and eye-hand coordination in adults: normative values for the Finger Tapping and Grooved Pegboard Tests.

Normative values for the Finger Tapping and Grooved Pegboard Tests were developed on a sample of 360 normal volunteers stratified according to gender, three educational groups ranging from 7 to 22 years, and four age groups subdivided between the ages of 16 to 70 years. Retest reliability was estimated for both measures. The Finger Tapping Test showed significant gender differences, since women were substantially slower, particularly in the older age groups. On the Grooved Pegboard Test, a converse gender difference was noted, since women were substantially faster than men. A smaller effect with increasing age resulted, and better educated individuals performed faster. If these motor and visuomotor tests are to be applied, then stratified normative estimates need to be implemented to provide viable clinical judgements.

Predictors of outcome following severe head trauma: follow-up data from the Traumatic Coma Data Bank.

Outcome as a function of employment status or return to school was evaluated in severely head-injured patients. A priori we selected the most salient demographic, physiological, neuropsychological and psychosocial outcome predictors with the aim of identifying which of there variables captured at baseline or 6 months would best predict employability at 6 or 12 months. Based on the patients evaluated at 6 months, 18% of former workers had returned to gainful employment and 62% of former students had returned to school. For those not back to work or school at 6 months, 31% of the former workers and 66% of the former students had returned by 12 months. Age, length of coma, speed for both attending and motor movements, spatial integration, and intact vocabulary were all significantly related to returning to work or school. The three most potent predictors for returning to work or school were intactness of the patient's verbal intellectual power, speed of information processing and age.

The Ruff 2 and 7 Selective Attention Test: a neuropsychological application.

The neuropsychological application of the Ruff 2 and 7 Selective Attention Test as a measure of visual selective attention was investigated. The instrument was constructed as a paper-and-pencil approach to evaluate sustained attention utilizing different distractor conditions in the study of voluntary or intentional aspects of attention. Four patient groups with cerebral lesions confined to either the right or left anterior or left or right posterior region (ns = 8, 8, 8, 6) were studied. Patients with right-hemispheric lesions showed a greater over-all reduction in processing speed independent of the serial or parallel processing mode in comparison to individuals with left-sided lesions. Furthermore, as predicted, the two groups with anterior brain damage showed a larger discrepancy between serial and parallel processing modes than patients with posterior lesions. Specifically, the right frontal cases showed the greatest differential of accuracy on the serial and parallel tasks.

Parallel and serial visual search after closed head injury: electrophysiological evidence for perceptual dysfunctions.

Event-related potentials (ERPs) were recorded from closed head injury (CHI) patients at least 2 years postinjury and from controls in order to assess their parallel and serial processing abilities during visual search. In Experiment 1, stimuli consisted of arrays of eight triangles; half of the arrays contained a target item. In the "feature-present" condition, the target item was a triangle with an additional horizontal line that could be detected automatically and in parallel, while in the "feature-absent" condition all items except for the target triangle had an additional horizontal line, thus requiring a serial search. In Experiment 2, stimuli consisted of eight solid bars (50%), seven solid bars and a vertical open bar (25%), and seven solid bars and a horizontal open bar (25%): the array containing the horizontal bar served as a target. By recording ERPs to the arrays containing vertical open bars, which were similar to the target items, parallel processing of "pop-out" stimuli could be studied in the absence of any overt response. ERP data were compared with the results of neuropsychological and neuroimaging (MRI, CAT) examination. Patient exhibited a decreased behavioral performance both in the parallel and in the serial processing mode. Furthermore, abnormalities of early and intermediate ERP components (P1, N1, P2, N2) were found, whereas the late component (P3) was less affected by CHI. The results were interpreted as an index of CHI-induced dysfunctions in perceptual processes such as simple feature registration and early target discrimination. It was suggested that these dysfunctions contribute to impairments of parallel as well as serial processes in visual search.

Neuropsychological sequelae of arteriovenous malformations.

A total of 24 patients harboring arteriovenous malformations (AVMs) in either the dominant hemisphere (n = 12) or the nondominant hemisphere (n = 12) were examined neuropsychologically. When compared with 24 matched normal control subjects, the AVM patients demonstrated differential degrees of impairment in verbal or visuospatial processing, depending on whether the lesion involved the dominant or nondominant hemisphere. As predicted, most compelling were the findings of cognitive deficit associated with the hemisphere contralateral to the AVM relative to matched normal control subjects. Evidence of higher cortical dysfunction contralateral to the residing AVM is discussed in the context of cerebrovascular steal.

Vegetative state after closed-head injury. A Traumatic Coma Data Bank Report.

To elucidate the clinical course of the vegetative state after severe closed-head injury, the Traumatic Coma Data Bank was analyzed for outcome at the time of discharge from the hospital and after follow-up intervals ranging up to 3 years after injury. Of 650 patients with closed-head injury available for analysis, 93 (14%) were discharged in a vegetative state. In comparison with conscious survivors, patients in a vegetative state sustained more severe closed-head injury as reflected by the Glasgow Coma Scale scores and pupillary findings and more frequently had diffuse injury complicated by swelling or shift in midline structures. Of 84 patients in a vegetative state who provided follow-up data, 41% became conscious by 6 months, 52% regained consciousness by 1 year, and 58% recovered consciousness within the 3-year follow-up interval. A logistic regression failed to identify predictors of recovery from the vegetative state.