Investigating the neurobiological basis of cognitive rehabilitation therapy with fMRI.

The neurobiological changes occurring during cognitive rehabilitation therapy (CRT) have yet to be systematically studied. In the present study, functional magnetic resonance imaging (fMRI) was used to demonstrate brain plasticity in response to CRT (n = 5) following mild traumatic brain injury. Neuropsychological tests and two fMRI activation tasks, a visually guided saccades and a reading comprehension task, were employed pre- and post-CRT. CRT was used to systematically address the identified deficits in visual scanning and language processing. As hypothesized, changes in the pattern and extent of activation within expected neuroanatomical areas occurred post-CRT. Changes in fMRI activation are discussed for each subject and related to changes on neuropsychological measures. This study demonstrates how fMRI can illustrate the neurobiological mechanisms of recovery in individual subjects. The variability in subject responses to CRT supports the notion of tailoring rehabilitation strategies to each subject in order to optimize recovery following brain injury.

Evidence-based cognitive rehabilitation: recommendations for clinical practice.

OBJECTIVE: To establish evidence-based recommendations for the clinical practice of cognitive rehabilitation, derived from a methodical review of the scientific literature concerning the effectiveness of cognitive rehabilitation for persons with traumatic brain injury (TBI) or stroke. DATA SOURCES: A MEDLINE literature search using combinations of these key words as search terms: attention, awareness, cognition, communication, executive, language, memory, perception, problem solving, reasoning, rehabilitation, remediation, and training. Reference lists from identified articles also were reviewed; a total bibliography of 655 published articles was compiled. STUDY SELECTION: Studies were initially reviewed according to the following exclusion criteria: nonintervention studies; theoretical, descriptive, or review papers; papers without adequate specification of interventions; subjects other than persons with TBI or stroke; pediatric subjects; pharmacologic interventions; and non-English language papers. After screening, 232 articles were eligible for inclusion. After detailed review, 61 of these were excluded as single case reports without data, subjects other than TBI and stroke, and nontreatment studies. This screening yielded 171 articles to be evaluated. DATA EXTRACTION: Articles were assigned to 1 of 7 categories according to their primary area of intervention: attention, visual perception and constructional abilities, language and communication, memory, problem solving and executive functioning, multi-modal interventions, and comprehensive-holistic cognitive rehabilitation. All articles were independently reviewed by at least 2 committee members and abstracted according to specified criteria. The 171 studies that passed initial review were classified according to the strength of their methods. Class I studies were defined as prospective, randomized controlled trials. Class II studies were defined as prospective cohort studies, retrospective case-control studies, or clinical series with well-designed controls. Class III studies were defined as clinical series without concurrent controls, or studies with appropriate single-subject methodology. DATA SYNTHESIS: Of the 171 studies evaluated, 29 were rated as Class I, 35 as Class II, and 107 as Class III. The overall evidence within each predefined area of intervention was then synthesized and recommendations were derived based on consideration of the relative strengths of the evidence. The resulting practice parameters were organized into 3 types of recommendations: Practice Standards, Practice Guidelines, and Practice Options. CONCLUSIONS: Overall, support exists for the effectiveness of several forms of cognitive rehabilitation for persons with stroke and TBI. Specific recommendations can be made for remediation of language and perception after left and right hemisphere stroke, respectively, and for the remediation of attention, memory, functional communication, and executive functioning after TBI. These recommendations may help to establish parameters of effective treatment, which should be of assistance to practicing clinicians.

Incorporation of SPECT imaging in a longitudinal cognitive rehabilitation therapy programme.

In this clinical study, five consecutive referrals to a cognitive rehabilitation therapy (CRT) programme were followed in a longitudinal protocol involving a resting SPECT and neuropsychological evaluation at pre-treatment, post-treatment, and post non-treatment intervals. All clients had acquired brain injury and initially demonstrated neuropsychological deficits and various degrees of hypoperfusion on SPECT. Statistical Parametric Mapping (SPM) was used to evaluate change in successive SPECT images. Following CRT, all clients were able to return to productive employment or schooling. Examination of the neuropsychological testing results revealed significant improvement in performance following CRT which were generally maintained during the non-treatment period. SPM analysis of the SPECT data revealed that, in a majority of cases, most of the significant increases in relative cerebral blood flow redistribution were seen during the treatment period, rather than the non-treatment period. The results suggest that, even in individuals who are more than 2 years post-brain damage, relative increases in rCBF can be demonstrated following individualized CRT and that most of these changes can be related to improvements on neuropsychological tests.

Cognitive rehabilitation therapy of brain-injured students in a public high school setting.

Cognitive rehabilitation therapy is a systematic effort to assist brain damaged individuals in developing ways to compensate for cognitive deficits. Although this treatment is considered standard in a field of rehabilitation, access to services is limited by the availability of specialists. A model for bringing cognitive rehabilitation techniques to children with acquired brain injury within their own school setting is presented. A convenience sample of 10 public high school students with acquired brain injury received biweekly cognitive rehabilitation sessions for 20 weeks. Treatment was based on a developmental model of brain functioning. Treatments were provided by trained school teachers under the supervision of psychologists specializing in cognitive rehabilitation. Students were evaluated pre- and post-treatment using neuropsychological tests. After treatment, the students demonstrated a significant increase in general memory ability (p < 0.05). These gains were due mostly to increases in verbal learning ability. Integration of cognitive rehabilitation therapy with public school services is a significant step in providing this valuable treatment to a wider range of children with acquired brain injury.

Impact of cognitive rehabilitation therapy on neuropsychological impairments as measured by brain perfusion SPECT: a longitudinal study.

Three patients, with known brain injury and neuropsychological impairments, are followed through an individualized cognitive rehabilitation programme and post discharge from the treatment programme. Single Photon Emission Computed Tomography (SPECT) of the brain was employed to evaluate resting relative cerebral blood flow (rCBF) during the process of recovery from brain injury. All patients experienced significant improvements on measures of neuropsychological functioning and improvements in rCBF during this longitudinal study. The specific changes in rCBF appear to be related to the location of the patient's brain injury and strategies particular to cognitive rehabilitation therapy. Continued improvements in rCBF, functional abilities, and cognitive skills were documented in these three cases up to 45 months post brain injury.

The Halstead Category Test: a fifty year perspective.

The Category Test, a major part of the Halstead-Reitan Neuropsychological Battery, was first described in a 1943 article by Halstead and Settlage. This paper reviews the development of the test, the psychometric properties of the instrument, available administration and scoring methods, discusses various interpretative strategies, and the empirical support for the test's clinical validity. Recent developments are then reviewed, as well as what the authors see as the future potential for this instrument.

The relationship between age, gender and psychological distress in rehabilitation inpatients.

Although commonly accepted as the dominant emotional reaction to functional loss, the reported occurrence of depression in rehabilitation patients varies widely. Rather than focusing solely on depressive symptoms, this study furthers our understanding of emotional distress following a functional loss by assessing a range of psychiatric symptoms. A series of rehabilitation patients admitted to an urban hospital inpatient unit is used as the sample (n = 48). Demographic, neuropsychological, and a functional independence measure were included as independent variables. The statistical analysis revealed that-although age was not correlated with years of education, functional status, or neuropsychological impairment-there was a significant inverse relationship between age and reported emotional distress. Utilizing MANCOVA to explore the impact of age and gender on specific groups of psychiatric symptoms revealed that both younger and male patients tended to express psychiatric symptoms more frequently. The importance of considering age and gender in evaluation of emotional distress in rehabilitation is supported in this comprehensive study of psychiatric symptoms.

Countertransference and the multiple amputee patient: pitfalls and opportunities in rehabilitation medicine.

Current psychoanalytic literature on countertransference broadly defines the term as a helping professional's overall response to an individual patient. Reactions of rehabilitation professional to their traumatically injured patients can significantly impact on the patient's treatment as well as the individual therapist's and entire rehabilitation team's effectiveness. In this paper, a case is presented illustrating a process of understanding countertransference toward a multiple amputee patient. Implications for the rehabilitation team are also described. The analysis of a single case demonstrates how countertransference interpretation might be used as a vehicle to enhance understanding the patient and promote team effectiveness.

Use of interdisciplinary education to foster familiarization among health professionals.

This paper describes a pilot interdisciplinary experience between the dental hygiene and medical technology programs at Marquette University. It was designed, in part, to familiarize dental hygiene students with the medical technology profession. Comments solicited from students on the final evaluation form indicated that this pilot project was highly successful and met the objectives. Affective, multiple-choice questions on pretests and posttests showed a positive change in attitude, but this change was not statistically significant. Possible reasons for this are discussed. Benefits of this pilot project were an improved understanding of medical technology on the part of the dental hygiene students, enhanced interdepartmental communication, and plans to develop a reciprocal interdisciplinary experience for the medical technology students. It is hoped that this pilot project will serve as a stimulus for similar experiences among other health science programs.

Neuropsychological testing and survey forms to indicate possible loss of neurological functioning.

Thirty spina bifida-hydrocephalic patients susceptible to changes in intracranial pressure and/or in spinal cord involvement underwent systematic surveillance of neurological, neuropsychological and behavioural status for up to two years. Behavioural status was monitored monthly through survey forms completed by direct caretakers while a neuropsychological battery was administered every three months. Patients were also followed in a Spina Bifida Clinic and definitive diagnosis of neurological change was determined through standard medical techniques. Analysis of results indicate that behavioural changes are often observed by direct caretakers and neurologists without occurrence of definitive neurological change. In contrast, the neuropsychological assessment revealed a group of reproducible measures that remain stable during periods of non-definitive neurological change. The neuropsychological measures provide quantitative information on the subjects' neurological function. This information can be used for comparison purposes after a period of stable neurological functioning has occurred.

Comparison of spina bifida, hydrocephalic patients and matched controls on neuropsychological tests.

Thirty adolescents with spina bifida and hydrocephalus were matched for age and I.Q. with thirty controls of different aetiology. A battery of eleven neuropsychological measures including the Wechsler Intelligence Scale, conceptual and planning skills, simple motor speed, simple tactile sensitivity, complex motor skill and complex tactile perception were administered to both groups. The index subjects differed from the controls in having a greater difference between verbal and performance I.Q., better complex motor skills, and slower left hand finger tapping speed. A step-wise multiple linear regression analysis correctly identified 80% of the subjects using the above three measures as the discriminating variables.

Antibiotic susceptibility of black-pigmented Bacteroides isolates from the human oral cavity.

The minimal inhibitory concentrations of penicillin and six other antibiotics were determined for 66 oral black-pigmented Bacteroides isolates by using the National Committee for Clinical Laboratory Standards proposed standard agar dilution technique. These results plus iodometric determination of beta-lactamase activity showed that oral isolates of black-pigmented Bacteroides are remaining relatively susceptible to commonly used antibiotics.