Computer-assisted training of executive functions in adult patients with non-progressive acquired brain damage - a pilot study on efficacy of a new therapeutic application.

Executive dysfunction is most often caused by post-traumatic or post-stroke damage to the prefrontal regions of the brain. The aim of this study was to compare the efficacy of two computer-assisted therapy programs for executive dysfunctions in patients with acquired brain injury. Patients were trained using either a newly developed application ExeSystem (designed to help improve the ability to manage and control one's own behavior by performing tasks imitating natural, everyday situations) or a combination of two commercial applications RehaCom and CogniPlus. Data collected after a three-week period of therapy conducted in two 15-person groups of participants indicated comparable efficacy of both therapy programs in improving quality of daily functioning, executive attention, as well as planning and problem-solving but not memory. The improvement in social competence (p = .028) was the only advantage of therapy with the ExeSystem. Therapeutic interactions using computer programs were shown to be positively evaluated by patients (p < .01). This study confirmed at least equal efficacy of computer-based executive function therapy using ExeSystem compared to RehaCom and CogniPlus. However, despite the implementation of a more ecological and comprehensive approach to the content of a new application, the benefits of this approach were limited.

Clinical Efficacy and Safety Profile of Anterior Thalamic Stimulation for Intractable Epilepsy.

INTRODUCTION: Deep brain stimulation of the anterior nucleus of the thalamus (ANT DBS) is a neuromodulation therapy for patients with refractory partial seizures. The ANT is the structure of a limbic system with abundant neuronal connections to temporal and frontal brain regions that participate in seizure propagation circuitry. STATE OF THE ART: We have performed a literature search regarding the clinical efficacy of ANT DBS. We discuss the surgical technique of the implantation of DBS electrodes with special attention paid to the targeting methods of the ANT. Moreover, we present in detail the clinical efficacy of ANT DBS, with a special emphasis on the stimulation parameters, a stimulation mode, and polarity. We also report all adverse events and present the current limitations of ANT DBS. CLINICAL IMPLICATIONS: In general, the safety profile of DBS in intractable epilepsy patients is good, with a low rate of surgery, hardware-related, and stimulation-induced adverse events. No significant cognitive declines or worsening of depressive symptoms was noted. At long-term follow-up, the quality-of-life scores have improved. The limitations of ANT DBS studies include a limited number of patients treated and mostly open-label designs with only one double-blind, randomized multicenter trial. Most studies do not report the etiology of intractable epilepsy or they include nonhomogeneous groups of patients affected by intractable epilepsy. There are no guidelines for setting initial stimulation parameters. All the variables mentioned may have a profound impact on the final outcome. CONCLUSIONS: ANT DBS appears to be a safe and efficacious treatment, particularly in patients with refractory partial seizures (three-quarters of patients gained at least 50% seizure reduction after 5 years). ANT DBS reduces most effectively the seizures originating in the temporal and frontal lobes. The published results of ANT DBS highlight promise and hope for patients with intractable epilepsy.

Neuronavigated 1 Hz rTMS of the left angular gyrus combined with visuospatial therapy in post-stroke neglect.

BACKGROUND: Visuospatial neglect (VSN) may be caused by an inter-hemispheric imbalance of neural activity after brain injury. Repetitive transcranial magnetic stimulation (rTMS) allows rebalancing restoration to a certain degree, relieving neglect symptoms. OBJECTIVE: This study investigates the therapeutic effect of 1 Hz rTMS applied over the left angular gyrus combined with visual scanning training in patients with left VSN in the subacute stroke phase. METHODS: Twenty-eight patients with VSN were randomly assigned to either experimental (fifteen sessions of rTMS consisted of 1800 magnetic pulses delivered to the left angular gyrus with a neuronavigation control), or control group (fifteen sessions of sham stimulation), followed by visual scanning training. VSN severity was assessed both before and after treatment with a 3-month follow up employing the Behavioural Inattention Test and functional measures. RESULTS: No statistically significant differences were detected in outcome measures between the rTMS and sham groups after completion of 3-week therapy and at 3-month follow up. The magnitude of stimulation effects was not associated either with lesion volume, its location, or baseline motor threshold. CONCLUSIONS: Our study did not confirm efficacy of 1 Hz rTMS over the angular gyrus as an adjuvant method to visual scanning training in patients with VSN in the subacute stroke.

Comprehensive cognitive training improves attention and memory in patients with severe or moderate traumatic brain injury.

Traumatic brain injury (TBI) leads to cognitive disorders, the most frequently affected functions being attention and memory. The present study aimed to investigate the effects of a cognitive rehabilitation program, consisting of individual and group interventions, on attention and memory in patients with TBI. Fifteen patients-in the postacute phase of recovery from moderate-to-severe TBI and subsequent cognitive disorders-were enrolled on a three-week waiting list and then underwent a three-week cognitive rehabilitation program. The patients were assessed using a set of five neuropsychological attention and memory tests. The patients and their caregivers were questioned to assess subjective changes in the everyday functioning of the former. The introduction of cognitive training was associated with improvement in one memory test and in two measures of attention. Mean effect size across all tests was higher over the period with treatment compared to the period without (d = 0.36 vs. 0.03). Both patients and caregivers reported significant improvements in everyday functioning (p < .05). There were no further improvements at the four-month follow-up assessment. A comprehensive program of cognitive rehabilitation may improve attention and memory, as well as everyday cognitive functioning, in patients with severe or moderate TBI.

Effects of group versus individual therapy for patients with memory disorder after an acquired brain injury: A randomized, controlled study.

INTRODUCTION: This randomized, controlled, single-blind study compared the efficacy of group versus individual memory rehabilitation therapy for patients with acquired brain injury (ABI). Subjects (N = 65) were assigned to individual (IT), group (GT), or no (NT) therapy during the three-week rehabilitation program. A neuropsychological assessment was conducted before treatment, immediately after completing treatment, and 4 months after completing treatment. Three levels of functioning were assessed: participation, disability, and impairment. The primary outcome measure was the Rivermead Behavioural Memory Test (RBMT). The results of the cognitive measures in the three groups at subsequent assessments were compared, and the effect sizes were calculated to investigate the magnitude of improvement. RESULTS: There were no significant changes in self-reported patient memory problems for the participation-level measures. However, relatives of participants in the GT group reported a decreased frequency of memory failures (p = .026). According to the ability-level measure (RBMT), both therapeutic groups had similar significant improvements (p < .001), and the effect sizes were large in both groups. Although the NT group also improved (p = .015), the effect size was small. The differences between the three groups were not significant according to analysis of variance (ANOVA). However, after therapy was completed, only the GT group continued to improve (p = .013). For the impairment-level measures, the IT group showed significant improvement post treatment in three out of four measures (p < .05). This group had medium effect sizes, while the other groups showed a small or marginal effect. CONCLUSIONS: Cognitive rehabilitation - either in a group or individually - led to equally enhanced memory functioning in ABI patients, but the effects were not significantly different from those for patients in the NT group. GT and IT had specific effects on different levels of functioning.

Visual disorders, the prosopometamorphopsia and prosopagnosia type in the early days after the onset of brain hemorrhagic stroke--a case report.

Presented case report illustrates symptoms of prosopometamorphopsia (PM) and prosopagnosia, observed in the early days after the onset of a hemorrhagic stroke resulting from a complication of endovascular treatment of intracranial aneurysms and the use of anticoagulation therapy. PM is a visual disorder in which faces are perceived as distorted. The female patient described in the present study reported that faces she looked at seemed younger or older than in reality or as if they were dirty, swollen, or with a grimace. She also experienced symptoms of prosopagnosia, which is difficulty of recognizing familiar faces of people (e.g., of her husband and daughter). In the interview 6 months after the first examination, the patient reported spontaneous withdrawal of the visual disturbances.

Diverse attention deficits in patients with neurologically symptomatic and asymptomatic Wilson's disease.

OBJECTIVE: Cognitive deficits in patients with Wilson's disease (WD) have been reported in several studies, but there was no detailed analysis of the various components of attention, one of the most significant factors of the executive system. Our study determined the pattern of deficits in attention subsystems in WD patients, including selective attention, divided attention, attention switching, and sustained attention. METHOD: We examined 67 WD patients using the Test of Everyday Attention (TEA)-33 participants with neurological symptoms and 34 who were neurologically asymptomatic, but most with mild hepatic dysfunctions. The results were compared with 43 matched healthy controls. RESULTS: The group of WD patients with neurological symptoms performed significantly worse (p < .05) in all components of attention: sustained attention, selective attention, divided attention, and attentional switching. WD patients without neurological symptoms exhibited significantly lower results in one component-sustained attention (p < .05). None of the TEA subtests scores were associated significantly with Unified Wilson's Disease Rating Scale scores, which may reflect that the cognitive and neurological consequences of WD are relatively independent. CONCLUSIONS: We found a deficiency in all components of attention in neurological WD patients. The most frequently disturbed function was attention switching. Relatively milder deficits concerned divided, selective, and sustained attention. These are all abilities creating the core of the executive system and are regulated by subcortical prefrontal circuits, which are usually dysfunctional in WD patients. In neurologically asymptomatic patients, an isolated deficit of sustained attention occurs; this may be a sign of mild hepatic encephalopathy.

Transcranial magnetic stimulation combined with speech and language training in early aphasia rehabilitation: a randomized double-blind controlled pilot study.

BACKGROUND: Functional neuroimaging studies with poststroke aphasia patients have shown increased activation of the unaffected hemisphere, which hypothetically reflects a maladaptive strategy of brain reorganization. OBJECTIVE: We investigated whether repetitive transcranial magnetic stimulation (rTMS) inhibiting the right-hemisphere homologue of Broca's area improves language restitution if combined with speech/language therapy. METHODS: Forty aphasic patients during the subacute phase of ischemic stroke were randomized to a 3-week aphasia rehabilitation protocol in combination with real or sham rTMS. Naming, repetition, and comprehension were assessed using the Boston Diagnostic Aphasia Examination at baseline, immediately after therapy, and 15 weeks after completing treatment. RESULTS: Although language functions improved in both experimental and control groups after 3 weeks, only slight group differences in degree of recovery were revealed between patients receiving rTMS and control participants. Follow-up revealed that severely aphasic rTMS patients demonstrated significantly greater improvement than patients receiving sham stimulation in repetition. CONCLUSIONS: Inhibitory rTMS applied to the right frontal language homologue is not effective for all poststroke aphasia patients, although it might benefit selected patients.

[The value of self-report methods in neuropsychological diagnostics of patients after brain injury]. / Wartosc pomiaru samoopisowego w diagnostyce neuropsychologicznej pacjentów z uszkodzeniem mózgu.

Self-report methods are commonly applied in medicine and psychology. However, their diagnostic value in assessment of patients with acquired brain damage can be limited due to a number of various difficulties encountered by these patients, including cognitive disorders, fatigue, similarity of psychopathological and somatic symptoms, psychological reaction to the disease and limited or lack of insight (anosognosia). In our article we highlight the most important limitations of application of popular frequently used questionnaires in evaluation of brain-injured patients. We also discuss the possible ways of adjusting self-report techniques to requirements of diagnostic process in this clinical population. Proposed modifications refer to, among others, specific construction of diagnostic tools (appropriate content and number of questions, methods of measuring responses), collecting information from relatives, using questionnaires along with more objective measures, and controlling conditions in which the assessment is carried out. Although relying only on self-report methods can be misleading, for an aware clinician it is still an important source of data on patient's subjective opinion and on the way they experience their symptoms.

Effect of low-frequency repetitive transcranial magnetic stimulation on naming abilities in early-stroke aphasic patients: a prospective, randomized, double-blind sham-controlled study.

BACKGROUND AND PURPOSE: Functional brain imaging studies with aphasia patients have shown increased cortical activation in the right hemisphere language homologues, which hypothetically may represent a maladaptive strategy that interferes with aphasia recovery. The aim of this study was to investigate whether low-frequency repetitive transcranial magnetic stimulation (rTMS) over the Broca's homologues in combination with speech/language therapy improves naming in early-stroke aphasia patients. METHODS: 26 right-handed aphasic patients in the early stage (up to 12 weeks) of a first-ever left hemisphere ischemic stroke were randomized to receive speech and language therapy combined with real or sham rTMS. Prior to each 45-minute therapeutic session (15 sessions, 5 days a week), 30 minutes of 1-Hz rTMS was applied. Outcome measures were obtained at baseline, immediately after 3 weeks of experimental treatment and 15 weeks; posttreatment using the Computerized Picture Naming Test. RESULTS: Although both groups significantly improved their naming abilities after treatment, no significant differences were noted between the rTMS and sham stimulation groups. The additional analyses have revealed that the rTMS subgroup with a lesion including the anterior part of language area showed greater improvement primarily in naming reaction time 15 weeks after completion of the therapeutic treatment. Improvement was also demonstrated in functional communication abilities. CONCLUSIONS: Inhibitory rTMS of the unaffected right inferior frontal gyrus area in combination with speech and language therapy cannot be assumed as an effective method for all poststroke aphasia patients. The treatment seems to be beneficial for patients with frontal language area damage, mostly in the distant time after finishing rTMS procedure.

Transcranial magnetic stimulation combined with physiotherapy in rehabilitation of poststroke hemiparesis: a randomized, double-blind, placebo-controlled study.

BACKGROUND: Low-frequency repetitive transcranial magnetic stimulation (rTMS) of the contralesional primary motor cortex (M1) may improve recovery in patients with hemiparetic stroke. OBJECTIVE: To evaluate the effectiveness of applying 1 Hz rTMS to the contralesional M1 in addition to physiotherapy during early rehabilitation for stroke patients with hand hemiparesis in a randomized, sham-controlled, double-blind study. METHODS: Forty patients with moderate upper extremity hemiparesis were randomized to receive 3 weeks of motor training (45 minutes daily) preceded by 30 minutes of 1 Hz rTMS applied to the contralesional M1 or 30 minutes of sham rTMS. Functional assessment of the paretic hand using the Wolf Motor Function Test was performed before, immediately after, and 3 months after completing treatment. RESULTS: No statistically significant differences were found between the experimental and the control group for hand function (Wolf Motor Function Test; P = .92) or the level of neurological deficit (National Institutes of Health Stroke Scale [NIHSS]; P = .82) after treatment. Effect sizes for the experimental (d = 0.5) and the control group (d = 0.47) were small. Similar results were observed at the 3-month follow-up. CONCLUSIONS: The findings did not suggest that rTMS suppression of the contralesional motor cortex augments the effect of early neurorehabilitation for upper limb hemiparesis. Larger trials that stratify subjects based on residual motor function or physiological measures of excitation and inhibition may identify responders in the future.