Characteristics of impaired awareness after traumatic brain injury.

Impaired awareness of the effects of brain injury is a commonly observed and poorly understood finding in traumatic brain injury survivors. Nonetheless, impaired awareness has been identified as a major factor in determining outcome for traumatic brain injury survivors. Review of previous studies of impaired awareness in this patient population revealed a number of preliminary findings regarding the nature of this phenomenon. The present paper presents the results of 2 new studies with a total of 111 traumatic brain injury patients conducted to bring further clarity to this area. Findings confirmed and extended many results of previous investigations. Specific findings included patient overestimation of functioning as compared to family member ratings, patient report of greater physical than nonphysical impairment, greater patient-family agreement on specific ratings of patient functioning than on general ratings, greater agreement of family and clinician ratings of patient functioning with each other than with patient self-ratings, and partial disagreement of different methods of measuring impaired awareness.

Neurologic improvement following shunt placement for post-traumatic hydrocephalus in a child.

Post-traumatic hydrocephalus (PTH) is a medical complication of traumatic brain injury (TBI). There have been numerous reports of functional gains after shunt placement for PTH in adults but only rare observations about children. In this report, we present a child with PTH who displayed dramatic neurologic improvement after shunting. A 7-year-old boy sustained a severe TBI in a motor vehicle accident. When admitted for rehabilitation, his eyes were spontaneously open and he withdrew all extremities to pain but failed to follow commands. In rehabilitation, he made slow, steady progress in his cognitive and physical abilities. A CT scan conducted two months post-injury revealed marked ventriculomegaly necessitating shunt placement. Post-surgery, he began to verbalize, and was oriented to personal information. This case suggests that in children as well as adults with severe TBI and limited cognitive recovery, the possibility of PTH should be considered.

Akathisia resulting from traumatic brain injury.

Restlessness and agitation are commonly reported early sequelae of traumatic brain injury (TBI). Severe restlessness (akathisia) is also observed in psychiatric patients as a result of the use of dopamine receptor blocking agents. A recent case study described akathisia in a patient with bilateral orbitofrontal lesions following TBI. We report a case of unusually marked motor restlessness (akathisia) following TBI in a 17-year-old woman. When admitted for rehabilitation she was alert but agitated, severely restless, and mute. She constantly paced her room and the hospital unit, repeatedly retracing the same route. MRI scan revealed large, well-delineated bifrontal contusions. During baseline evaluation prior to anticipated psychopharmacological intervention her restlessness began to resolve rapidly. She became verbal and oriented within expected limits without medication. This case lends support to the observation that akathisia is related to lesions of the prefrontal cortex.

Improving functional skills using behavioral procedures in a child with anoxic brain injury.

Using a multiple baseline design, a behavioral treatment program was used to improve the functional abilities of a 12-year-old child with anoxic brain injury. Neuropsychological testing indicated marked amnesia and global cognitive deficits. Functionally, self-care tasks could be performed, but only with verbal cues and moderate physical assistance. Introduction of a monetary reward system significantly reduced the number of verbal cues and the amount of physical assistance necessary to perform two categories of activities of daily living: toileting/undressing and dressing. Results indicated decreases of 80% and 70% in the number of verbal cues and instances of physical assistance required to complete dressing, and reductions of 92% and 75% in the number of verbal cues and the amount of physical assistance necessary to complete toileting/undressing, respectively. Time to task completion was also decreased for both activity categories. A 6-month follow-up revealed that treatment gains had been maintained.

Behavioral treatment of adipsia in a child with hypothalamic injury.

Damage to the hypothalamic region is known to affect a wide range of homeostatic and adaptive functions, including water and food regulation, temperature control, hormone secretion and behavior. Deficient thirst is a serious consequence of hypothalamic injury, since water losses are not replaced by drinking. The effectiveness of behavioral procedures in increasing drinking is described for a child with diminished thirst secondary to hypothalamic injury.

Temperature biofeedback and relaxation training in the treatment of migraine headaches. One-year follow-up.

In a previous controlled group outcome study, a comparison of temperature biofeedback with progressive relaxation indicated that relaxation training was more effective in reducing migraine headache activity at the end of treatment. However, follow-up data obtained at 1, 2, and 3 months after the completion of treatment showed no difference between the two groups on any dependent measure. In the current study, 18 of 26 subjects who completed treatment in the original investigation collected headache data and completed a headache questionnaire 1 year subsequent to the conclusion of treatment in order to evaluate the long-term effectiveness of the two treatments. The results indicated that gains achieved in the reduction of headaches during both treatments were maintained at a 1-year follow-up. With the exception of medication consumption (for which relaxation training led to better long-term results) the 1-year follow-up data reveal no differential efficacy for temperature biofeedback or progressive relaxation in treating migraine headaches.

Biofeedback and relaxation training in the treatment of psychophysiological disorders: or are the machines really necessary?

The literature on the use of biofeedback and various forms of relaxation training in the treatment of psychophysiological disorders was reviewed; special attention was devoted to studies in which biofeedback and some form of relaxation training were compared. Based on this review, we conclude that there is no consistent advantage for one form of treatment over the other with any psychophysiological disorder for which a comparison has been made, e.g., essential hypertension, migraine headaches, premature ventricular contractions, tension headaches, temporomandibular joint pain, asthma, primary dysmenorrhea, and functional diarrhea. For other disorders in which no comparisons have been made (e.g., Raynaud's disease, sinus tachycardia, peptic uclers, and fecal incontinence) biofeedback seems to be a very promising treatment modality.

Temperature biofeedback in the treatment of migraine headaches: a controlled evaluation.

After an initial four-week baseline phase, during which daily records of headache frequency and intensity and daily medication records were kept, 30 patients with frequent (at least one per month) migraine headaches were randomly assigned to three conditions: (1) temperature biofeedback, autogenic training, and regular home practice; (2) progressive relaxation with regular home practice; and (3) a waiting-list control condition. Comparisons of headache data from the four weeks of baseline and last two weeks of treatment showed that both the relaxation and biofeedback groups improved significantly on total headache activity, duration of headaches, and peak headache intensity and reduced consumption of analgesic medication, while the waiting list control group did not. All three groups showed significant decreases in headache frequency. Although the relaxation training was more effective than biofeedback training at the last week of treatment, follow-up data at one, two, and three months showed no differences between the two treated groups on any dependent measure.

Preservation of cross-modal transfer of a rate discrimination in the bushbaby (Galago senegalensis) with lesions of posterior neocortex.

The effect of lesions of posterior neocortex was assessed, using a test method that permits the demonstration of cross-modal transfer in intact bushbabies. Eight bushbabies were trained to discriminate light flashes of 18/sec and 3/sec in a go-no-go shock-avoidance task. On completion of training, four bushbabies received lesions of posterior neocortex by aspiration. After 6 wk both lesion and intact animals were returned to training in the visual discrimination. On the day following criterion performance on the visual tests, auditory clicks off the same rate and contingencies were substituted and maintained to criterion. All eight bushbabies demonstrated rapid transfer and the lesion animals were not retarded as compared with intact subjects. The cross-modal transfer of a specific rate discrimination was thus preserved in the absence of posterior intersensory neocortex. The results are discussed in terms of a hypothetical subcortical system capable of the amodal coding of simple stimulus dimensions.