Assessing Children's Executive Function: BADS-C Validity.

OBJECTIVES: To investigate the external and ecological validity of a standardized test of children's executive functioning (EF), the Behavioral Assessment of the Dysexecutive Syndrome for Children (BADS-C). BACKGROUND: There are few standardized measures for assessing executive functions in children, and the evidence for the validity of most measures is currently limited. METHOD: A normative sample of 256 children and adolescents from age 8-16 years completed the BADS-C, and a parent or teacher completed rating scales of the child's everyday problems related to EF (Children's version of the Dysexecutive Questionnaire; DEX-C) and Strengths and Difficulties Questionnaire (SDQ), a commonly used measure of emotional, social, cognitive, and behavioral problems. RESULTS: Exploratory factor analyses yielded a two-factor structure to the BADS-C, indicative of monitoring and abstract reasoning processes, and a three-factor structure to the DEX-C, reflecting behavioral, and cognitive components of the dysexecutive syndrome as well as emotional responsiveness. Regression analyses showed significant relationships between BADS-C scores and everyday functioning as reported on the DEX and SDQ. Furthermore, there were significant differences in BADS-C scores between those children in the upper and lower quartiles on the SDQ. CONCLUSION: Results provide tentative evidence of BADS-C and DEX-C construct, convergent and predictive validity.

Neurocognitive outcomes in adults following cerebral hypoxia: A systematic literature review.

BACKGROUND: Hypoxic ischemic brain injury (HIBI) occurs as a result of complete or partial disruption of cerebral oxygen supply. The physical and cognitive sequelae of adults following hypoxia varies widely. OBJECTIVE: To systematically review studies exploring the neuropsychological outcomes following hypoxic brain insult in adults. METHODS: Data was sourced using six databases (CINAHL, Cochrane, Embase, Medline, PsycInfo and Web of Science). Initial MESH terms identified 2,962 articles. After a three-stage independent review process, 18 articles, 9 case studies and 9 group studies were available for data synthesis from 1990-2012. Case study data was converted to standardised scores and compared to available test norms. Cohen's d was calculated to permit group data interpretation. RESULTS: Intellectual decrement was observed in some studies although difficult to delineate given the lack of use of measures of premorbid ability. Cognitive sequelae varied albeit with predominant disturbance in verbal memory, learning ability and executive function observed across studies. Wechsler Memory Scale Revised (WMS-R) visual memory was comparable to normative data. Impaired Rey Osterrieth Complex Figure (ROCFT) performance was found among group studies. Across visuo-constructional and attention domains, performance varied, although no significant difference relative to reported means was observed. CONCLUSIONS: Future studies should consider the use of standardised assessment protocols, which include measures of premorbid functioning and performance validity.

'Thunder bolts and lightning': survival and neurorehabilitation following out of hospital cardiac arrest secondary to lightning strike.

BACKGROUND: There is a limited evidence base to inform patient management following lightning-induced injuries. CASE REPORT: A 36-year-old right-handed Caucasian male struck by lightning while outdoors suffered an out-of-hospital cardiac arrest with a recorded 50-min interval before the restoration of spontaneous circulation. Multiple life threatening injuries were sustained and a profound peripheral neuropathy developed. Cognitively, he was remarkably intact. We document his acute admission and his recovery during an inpatient stay in a UK-based Neurorehabilitation Unit. CONCLUSION: Intensive neurorehabilitation in this case improved functional independence and facilitated neuropsychological recovery, to the point that our patient was discharged to independent living. This case offers some support to the hypothesis that the electrical activity of a lightning strike can be both cardioprotective and neuroprotective, and that prolonged cardiopulmonary resuscitation is warranted in such cases.

Impact of paroxysmal sympathetic hyperactivity on nutrition management after brain injury: a case series.

OBJECTIVE: To review the nutritional requirements of all new inpatient brain injury admissions presenting with Paroxysmal Sympathetic Hyperactivity (PSH) in the rehabilitation setting. METHODS: RABIU is a 25-bed Regional facility in Northern Ireland which opened in 2006. All records of patients with a single episode non-progressive acquired brain injury admitted to RABIU from 2006 until the present were reviewed for evidence of PSH. Dietetic assessment and management was examined and recorded. RESULTS: Four patients with persisting paroxysmal sympathetic hyperactivity were identified. All patients displayed dystonia and posturing and had clinically important percentage weight loss. All had nutrition and/or hydration requirements markedly above their estimated requirement for slow weight gain, despite adjustment for brain injury. All four had posture-related complications of their dystonia and nutrition. CONCLUSION: Careful monitoring of nutrition, hydration and mineral supplementation is paramount in patients presenting with paroxysmal sympathetic hyperactivity after brain injury. It is argued that morbidity may be reduced by aggressive and expert nutrition management.

Maintaining community living with post brain injury agitation: a role for sodium valproate.

BACKGROUND: There is limited evidence to support pharmacological interventions for post-brain injury agitation and aggression. CASE REPORT: The case of Patient A, a man with severe agitation and aggression post-brain injury, highlights the successful use of sodium valproate, in the maintenance of community living, which had been threatened by the breakdown of the care package for this lone-dwelling individual. CONCLUSIONS: The case uniquely illustrates the effect of the drug due to a washout period, albeit due to patient non-compliance, allowing comparative observations both on and off and again on medication. In addition, Patient A's aphasia brings to the fore the difficulty with managing such symptoms and the ability of aphasic persons to avail of services and neurobehavioural therapies.

Subarachnoid haemorrhage (SAH): long-term cognitive outcome in patients treated with surgical clipping or endovascular coiling.

PURPOSE: To compare long-term cognitive outcomes of patients treated with surgical clipping or endovascular coiling after subarachnoid haemorrhage (SAH). METHOD: Retrospective matched cohort study assessed neuropsychological functioning at least 12 months after aneurysmal SAH treatment. Fourteen patients treated by endovascular coiling and nine patients treated by surgical clipping participated. After gaining written consent, a comprehensive neuropsychological battery was completed. Standardised tests were employed to assess pre-morbid and current intellectual functioning (IQ), attention, speed of information processing, memory and executive function as well as psychosocial functioning and affect. RESULTS: Treatment groups were not significantly different in terms of age, pre-morbid IQ, time from injury to treatment or time since injury. A significant effect of treatment on full-scale IQ score (p = 0.025), performance IQ (p = 0.045) and verbal IQ score (p = 0.029), all favouring the coiled group was observed. A medium effect size between groups difference in immediate memory (p = 0.19, partial η(2) = 0.08) was also observed. No significant between group differences on attention, executive functioning and speed of information processing measures or mood and psychosocial functioning were noted. Both groups reported increased anxiety and memory, attention and speed of information processing deficits relative to normative data. CONCLUSIONS: Study findings indicate fewer cognitive deficits following endovascular coiling. Cognitive deficits in the clipped group may be due in part to the invasive nature of neurosurgical clipping. Further prospective research with regard to long-term cognitive and emotional outcomes is warranted. IMPLICATIONS OF REHABILITATION: • Treatment of ruptured intracranial aneurysms by either endovascualar coiling or neurosurgical clipping can result in significant long-term physical disability as well as cognitive impairment. • Observed cognitive impairment(s) tend to be less in patients following endovascular coiling. • Following ruptured aneurysm, patients with cognitive impairment report reduced health related quality of life and increased anxiety. • Those with identified cognitive impairment(s) may benefit from cognitive remediation.

Effectiveness of neurodisability simulation training for NHS staff working in brain injury rehabilitation.

PURPOSE: Members of a regional inter-disciplinary neuro-rehabilitation service took part in simulation exercises aimed at providing insights into the lived experience of those with a neurodisability. The purpose of the study was to evaluate the impact of training on reflective clinical practice. METHOD: A sample of 78 professionals working within a U.K. regional neuro-rehabilitation service took part in neurodisability simulation exercises. Participants were drawn from all healthcare professions represented within the neuro-rehabilitation team. Quantitative and qualitative feedback was collected pre- and post-study and 3 months later. Length of working experience was examined as a possible mediating factor influencing attitudes towards and outcome of simulation training. RESULTS: Results suggest that participants found the simulation exercise experience insightful and increased their self-reported empathy and concern for those they care for. It also helped inform practical ways of working with patients. Length of staff experience was not found to be a significant factor in attitudes towards or outcome of the training. CONCLUSIONS: Simulation exercises, when organised with the aim of developing insight and empathy can result in positive outcomes for those who take part. Simulation exercises as an integrated learning tool for staff within healthcare settings should be provided.

Analysis of intensive outpatient neuro-rehabilitation outcomes using FIM+FAM(UK).

OBJECTIVE: To analyse the functional outcomes of adults following acquired brain injury attending an intensive outpatient neuro-rehabilitation programme relative to a comprehensive TBI day programme service in the United States. DESIGN: Retrospective audit of all admissions over a two-year period (2001-2003) to an outpatient neuro-rehabilitation service utilising an interdisciplinary team model. SETTING: Outpatient neuro-rehabilitation service. PARTICIPANTS: 89 patients in receipt of 2+ therapies attending for intensive day neuro-rehabilitation programme. MAIN OUTCOME MEASURES: Routine FIM+FAM(UK) scores were compiled on admission and discharge. The FIM+FAM(UK) is a widely employed outcome measure of activity and participation comprising 30 items across a range of domains including self care, domestic skills, mobility, communication, cognitive and social abilities. The scale is divided into two broad domains of functioning (motor and cognitive). DATA ANALYSIS: Descriptive analysis of demographic, patient diagnosis, referral patterns and time since injury to attendance was undertaken. Analysis of FIM+FAM(UK) admission and discharge scores was performed. RESULTS: Complete admission and discharge scores were available for 65 patients. Significant mean improvements in motor (12.0 point change), cognitive (7.3 point change) and composite FIM+FAM(UK) (19.3 point change) scores were observed indicating reduced functional dependence following an intensive period of outpatient neuro-rehabilitation. CONCLUSION: The FIM+FAM(UK) measure demonstrated sensitivity to change across functional domains relevant to goal directed intensive outpatient interdisciplinary neuro-rehabilitation.

Analysis of Wessex Head Injury Matrix (WHIM) scores in consecutive vegetative and minimally conscious state patients.

Consensus guidelines defining minimally conscious state (MCS) have been available for some years. However, to date, few measures have been developed that are particularly suited to monitoring MCS patients and there are limited clinical outcome data. The objective of the study was to determine the value of serial repeated assessments using the Wessex Head Injury Matrix (WHIM) to identify changes in vegetative state (VS) and MCS patients. Twenty consecutive VS/MCS patients admitted to a post-acute regional neurorehabilitation unit were assessed using WHIM. Significant differences in both total number of behaviours observed (p < .001) and highest rank behaviour were observed (p = .001) between initial and final WHIM assessments. Preliminary findings suggest that the WHIM is a sensitive measure of subtle changes in VS and MCS patients.

Single case experimental design study of Carer facilitated Errorless Learning in a patient with severe memory impairment following TBI.

OBJECTIVES: To investigate if errorless learning applied by carer(s) in an everyday setting can reduce the frequency of everyday memory problems following severe traumatic brain injury (TBI). RESEARCH DESIGN: Multiple baseline single case experimental design. METHODS AND PROCEDURES: A patient with severe memory impairment, six years post TBI was recruited via an outpatient neurorehabilitation clinic. ABA analysis was conducted using daily frequency counts of everyday memory problems as an index of change. EXPERIMENTAL INTERVENTION: Errorless learning delivered by the patient's carer, aimed at reducing the occurrence of identified everyday memory problems. The carer was guided in treatment implementation by an Occupational Therapist. MAIN OUTCOMES AND RESULTS: Incidence of frequently occurring memory lapses was significantly reduced (p< 0.001) and this was maintained at 3 months post intervention. CONCLUSION: This study highlights the potential clinical value of errorless learning with self-generated cues applied by carers within an everyday setting.

Vegetative and minimally conscious state(s) survey: attitudes of clinical neuropsychologists and speech and language therapists.

PURPOSE: To gauge the understanding and opinions of clinical neuropsychologists and speech and language therapists (SLT) in relation to vegetative (VS) and minimally conscious (MCS) patients relative to available practice guidelines. METHOD: Semi-structured questionnaires were sent to all UK Practitioner Full Members of the BPS Division of Neuropsychology (307) and SLT managers (371) in March to April 2002 examining post qualification clinical practice, professional-family involvement and views on neuro-rehabilitation access. Difference(s) in clinical practice among clinical neuropsychologists and SLTs were observed. RESULTS: Some 27% returned questionnaires (n=184). Despite significant working experience, most respondents poorly defined both VS and MCS. Among clinical neuropsychologists and speech and language therapists not working with these patients, less positive attitudes regarding the value of neuro-rehabilitation were endorsed. CONCLUSIONS: Despite the development of SMART training for VS, there is a dearth of specific training in MCS assessment and management. The need to improve professional understanding among these staff groups is highlighted.

Independent living following a 'Do Not Resuscitate' order after subarachnoid haemorrhage.

PURPOSE: The recovery and psychosocial adjustment of a 41-year-old right handed women (K.E.) following subarachnoid haemorrhage (SAH) with initially poor predicted prognosis is presented. METHOD: A single case report with an early post surgery 'Do Not Resuscitate' order following SAH with a significant period of impaired consciousness is outlined. RESULTS: Following a right frontal craniotomy and clipping of a left distal anterior communicating artery (AcoA) aneurysm, K.E. was unresponsive for 23 days and 'minimally conscious' for a further 5+ weeks post surgery (36 days). At two months post insult, after some neurological improvement, she was transferred for post-acute goal directed neurorehabilitation. At 8 months post insult, after 4 months inpatient and 2 months intensive outpatient neurorehabilitation, K.E. was largely independent, did not require home care services and had made a good psychosocial adjustment to her acquired difficulties. CONCLUSIONS: The potential for recovery following a significant period of reduced consciousness after SAH is highlighted despite initially poor prognostic indicators.

Vegetative and minimally conscious states: serial assessment approaches in diagnosis and management.

Assessment of vegetative (VS) and minimally conscious state (MCS) patients presents clinicians with inherent difficulties (Royal College of Physicians, 2003) in terms of the reliable detection of potential signs of awareness given that all current assessment tools rely on observed behaviour. Recently developed measures such as SMART (Gill-Thwaites & Munday, 1999) and WHIM (Shiel et al., 2000), employing structured operational defined behavioural observations can facilitate the serial assessment of patient awareness, progress and appropriate goal setting particularly as one-off bedside assessments are more likely to be inaccurate. The use of sensitive tailored approaches involving experienced multidisciplinary teams is strongly advocated (Royal College of Physicians and British Society of Rehabilitation Medicine, 2003), notwithstanding clinicians should carefully consider potential confounding clinical factors, which may deleteriously influence patient arousal or ability to respond. Finally, areas for future development and recommendations regarding multidisciplinary assessment approaches with VS and MCS patients are outlined.

The effect of contralesional limb activation training and sustained attention training for self-care programmes in unilateral spatial neglect.

PURPOSE: To evaluate the effectiveness of two rehabilitation techniques for unilateral spatial neglect, contra-lesional limb activation and sustained attention training, on impaired activities of daily living. METHODS: Two single case, time-series designs incorporating baseline, intervention and post-intervention phases. RESULTS: Significant improvements were observed in both neuropsychological measures and in the independent performance of everyday activities coincident with the start of training. The benefits were well maintained during the post-training period. CONCLUSIONS: The results support the use of the two techniques in achieving functional goals for unilateral neglect patients.