Quantitative assessment of impairment in constructional ability by cube copying in patients with aphasia

Constructional apraxia was evaluated in patients with aphasia using a cube-copying task. It was assessed whether quantitative assessment of cube copying could be used to estimate the performance intelligence quotient (IQ) according to neuropsychological tests. Abnormality in the cube-copying test was observed in 42 of 46 patients (91.3%). Performance according to Raven's coloured progressive matrices and the revised Wechshler adult intelligence scale (WAIS-R) in patients with poor cube copying was significantly lower than in the other four patients. Numbers of the connections completed and plane-orientation errors made in the cube-copying test were significantly correlated with performance IQ on the WAIS-R, correlating particularly with block design, digit symbol, and object assembly in performance IQ subtests. The quantitatively scored cube-copying test, then, can roughly predict non-verbal IQ in patients with aphasia.     

The utility of the Mini-Mental Status Exam in older adults with traumatic brain injury

Primary objective: To assess the utility of the Mini-Mental Status Examination (MMSE) among the older TBI population.

Methods and procedures: The MMSE and a number of other neuropsychological tests were administered to forty-three adults aged 50 and over one year following mild to moderate TBI. The sensitivity, specificity, and predictive value of the MMSE were evaluated in relation to these tests.

Main outcomes and results: The domains of the MMSE generally exhibited low sensitivity while high specificity was demonstrated by Attention and Language. Positive predictive value was high only for Language but negative predictive value was moderate to high for all domains.

Conclusions: These results suggest that one year following mild to moderate TBI among older adults, the MMSE should not be used to identify those with cognitive impairment; if administered, a perfect score on a component of the MMSE suggests that enhanced testing in that given domain may not reveal further impairment. A small sample size and a small number of those impaired limit our results.     

Beneficial effect from a cognitive training programme on children with acquired brain injuries demonstrated in a controlled study

Primary objective: To test the effectiveness of a cognitive training programme in children and adolescents with attention and memory deficits after acquired brain injury (ABI).

Research design: Randomized controlled study.

Participants: Thirty-eight children with ABI, 9-16 years of age.

Methods and procedures: The treatment group trained with the cognitive programme for 30 minutes per day interactively with a teacher or parent for a period of 17 weeks. Children in the control group had a freely chosen interactive activity 30 minutes daily for 17 weeks. Pre- and post-training assessments were made using a neuropsychological test battery.

Main outcome and results: Significant improvements in the majority of neuropsychological tests of sustained and selective attention as well as in memory performance were shown in the treatment group as compared to controls.

Conclusions: The immediate effect of the training programme improved complex attention and memory functions, indicating that this method may be a valuable treatment option for improving cognitive efficiency in children after ABI. On the basis of these results, the next step will be to evaluate long-term effects and further ecological validity.     

Factors influencing driving 10 years after brain injury

Objective: To study long-term consequences of brain injury on health status, driving characteristics and car accidents. To study whether driving 10 years after brain injury was retrospectively related to cognitive functioning and on-road driving performance 10 years before.

Research design: A semi-structured telephone interview with 38 patients with sequelae of brain injury and 49 healthy controls was used.

Results: Hypertension, heart disease and vascular disorder were the most frequently reported diseases. The patients reported fatigue, irritability, memory and initiative problems. Concentration and vision problems influenced their driving. Patients had more car accidents reported to an insurance company during the observation period than control subjects. Present driving was retrospectively significantly related to neuropsychological test results but not to on-road test outcome 10 years before. Car accidents were not related to neuropsychological test results or to on-road test outcome 10 years back. Half of the dropouts were stroke patients and they performed significantly worse on the neuropsychological tests but not on the on-road test 10 years before.

Conclusion: Neuropsychological tests focusing on information processing speed and attention is a useful screening tool for predicting driving competence. Stroke patients are vulnerable if they continue to drive and need to be evaluated for their driving capacity to drive.     

Computed tomography findings and early cognitive outcome after traumatic brain injury

Primary objective: To examine the relationship between CT abnormalities and early neuropsychological outcome following traumatic brain injury (TBI) using quantitative CT analyses, data reduction methods for neuropsychological results and specific hypotheses based on literature review.

Research design: Observational, prospective cohort study using acute (emergency) CT data and neuropsychological test data from 89 participants with TBI who were hospitalized for rehabilitation.

Methods and procedures: Principal components analysis with varimax rotation was used to reduce data from a standard battery of eight neuropsychological tests administered after clearance of post-traumatic amnesia (1 month post-TBI on average). Bivariate correlations were used to examine relationships of three factors (verbal memory, cognitive processing speed and verbal working memory) to quantitative volumetric analysis of CT scan abnormalities (size, number and location). Specific hypotheses as to CT predictors of poor performance on each factor were tested using multivariable linear regression that included injury severity and demographic variables.

Main results: Eighty-nine per cent of participants had some pathology on initial CT. Age, education and time to follow commands (TFC), an index of overall injury severity, were significantly associated with the neuropsychological factors. However, none of the specific hypotheses about CT scan variables and cognitive outcome were strongly supported by the data. There was a trend for any CT abnormality to predict slower speed of processing and for higher number of brain lesions to predict worse memory performance.

Conclusions: Despite the precision added by quantitative CT analysis, CT findings did not improve on demographic factors and TFC in predicting early cognitive outcome of TBI. Imaging methods that are more sensitive to white matter integrity may be needed to develop pathophysiologic predictors of TBI outcome.     

The relationship between working memory, processing speed, verbal comprehension and FAS performance following traumatic brain injury

Primary objective: To investigate the relationship of working memory, processing speed and verbal comprehension with FAS performance in individuals who had sustained a traumatic brain injury (TBI).

Methods and procedure: Sixty-three patients with a TBI were grouped according to the presence of impaired verbal fluency performance and then compared on a number of cognitive and demographic variables.

Results: Following a TBI, working memory and processing speed had the greatest influence on verbal fluency performance. For those individuals who have not sustained a TBI, education, verbal intelligence, working memory and speed of information processing were related to FAS performance.

Conclusions: The findings of the study indicate that FAS performance was related to verbal intelligence, working memory ability, attention and speed of information processing. The results further suggest that different variables are related to FAS performance following a TBI as compared with control group performances.     

Short-term DTI predictors of cognitive dysfunction in mild traumatic brain injury

Primary objective: To explore whether baseline diffusion tensor imaging (DTI) metrics are predictive of cognitive functioning 6 months post-injury in patients with mild traumatic brain injury (MTBI).

Research design: Seventeen patients with MTBI and 29 sex- and age-matched healthy controls were studied.

Methods and procedures: Participants underwent an MRI protocol including DTI, at an average of 4.0 (range: 1-10) days post-injury. Mean diffusivity (MD) and fractional anisotropy (FA) were measured in the following white matter (WM) regions: centra semiovale, the genu and the splenium of the corpus callosum and the posterior limb of the internal capsule. Participants underwent neuropsychological (NP) testing at baseline and at 6-month follow-up. Least squares regression analysis was used to evaluate the association of MD and FA with each NP test score at baseline and follow-up.

Main outcomes and results: Compared to controls, average MD was significantly higher (p = 0.02) and average FA significantly lower (p = 0.0001) in MTBI patients. At the follow-up, there was a trend toward a significant association between baseline MD and response speed (r = -0.53, p = 0.087) and a positive correlation between baseline FA and Prioritization form B (r = 0.72, p = 0.003).

Conclusions: DTI may provide short-term non-invasive predictive markers of cognitive functioning in patients with MTBI.     

Cerebral anoxia and disability

Objectives: To describe the sequelae of cerebral anoxia following out-of-hospital cardiac arrest, to study the functional outcome and to seek a link between the acute stage and the disability.

Method: A retrospective study was performed. The initial findings and the neurological and neuropsychological status are recorded of 12 patients admitted to the rehabilitation unit for after-effects of cerebral anoxia following out-of-hospital cardiac arrest.

Results: After clinical and neuropsychological assessment, all patients displayed cognitive impairment. Two groups of patients appeared: seven patients were severely disabled with a dysexecutive and behavioural frontal lobe syndrome and memory deficit; five out of the seven also presented an extra-pyramidal syndrome; the other five patients presented behavioural dysfunction related to frontal lobe disorder but were independent in daily life activities. No correlation was found between the acute stage data and the outcome.

Conclusion: Neurological and neuropsychological impairment after cerebral anoxia may be severe but seems difficult to predict. A dysexecutive syndrome was noted in all 12 patients.     

Awareness of activity limitations, goal setting and rehabilitation outcome in patients with brain injuries

Primary objective: To examine the relationship between self-awareness, goal setting ability (i.e. ability to set realistic goals) and performance/outcome in a cognitive task and for rehabilitation.

Research design: Regression analyses were conducted to compare the predictive power of self-awareness and demographic/neuropsychological variables on goal setting ability and performance/outcome.

Methods and procedures: Self-awareness of 63 patients with brain injuries was measured by direct clinicians' rating and the difference between patient and staff ratings in a questionnaire.

Results: The awareness measures predicted 32% of the variance for goal setting ability in the rehabilitation context but only 4% of the goal setting variance in the cognitive task. Similarly, self-awareness predicted 33% of the variance for rehabilitation outcome but only 5% of the performance in the cognitive task.

Conclusions: Self-awareness seems to be related to goal setting ability and outcome in a long-term rehabilitation process but less in short-term experimental tasks.     

Neuropsychological function 23 years after mild traumatic brain injury: a comparison of outcome after paediatric and adult head injuries

Primary objective: To the authors' knowledge no study comparing very long-term neuropsychological outcome after mild paediatric and adult traumatic brain injury (TBI) has been published. The primary objective of this study was to compare neuropsychological outcome 23 years after mainly mild paediatric and adult TBI.

Research design: The study was a neuropsychological follow-up 23 years after a prospective head injury study conducted at a Norwegian public hospital.

Methods and procedures: One hundred and nineteen patients were assessed with a comprehensive neuropsychological test battery. Of these, 45 were paediatric TBI and 74 were adult TBI.

Main outcomes and results: Both the paediatric and adult groups obtained scores in the normal range. In the paediatric group significant relationships were found between head injury severity and current neuropsychological function. The most important predictors of poor outcome were length of post-traumatic amnesia (PTA) and a combination of PTA and EEG pathology within 24 hours of injury. No influence of pre- and post-injury risk factors on current neuropsychological function was evident.

Conclusions: The findings indicate that children sustaining complicated mild TBI may be more vulnerable to development of chronic mild neuropsychological dysfunction than adults sustaining similar head injuries.     

Two case studies in the application of errorless learning techniques in memory impaired patients with additional executive deficits

Primary objective: The purpose of the present study was to examine in what extent errorless learning can be applied to amnesic patients with additional executive dysfunction.

Research design: Two case studies were used in which two patients with severe closed head-injury were compared according to their different neuropsychological profiles.

Methods and procedures: Patients were taught complex semantic information about their therapists and cognitive procedures needed to programme an electronic organizer.

Main outcomes and results: Both semantic and procedural results suggest that the errorless method can be very helpful for teaching complex new knowledge to amnesic patients with mild executive impairment, whereas the presence of a dysexecutive syndrome may hamper the success of this form of memory rehabilitation.

Conclusions: The present study puts forward that executive deficits should be taken into account when neuropsychologists are planning to use errorless techniques.     

Neurocognitive fitness in the sub-acute stage after mild TBI: the effect of age

Objective: Age is assumed to be a negative prognostic factor in recovery from moderate-to-severe traumatic brain injury (TBI). Little is known on cognitive performance after mild TBI in relation to age in the sub-acute stage after injury.

Method: Ninety-nine mild TBI subjects (age 15-75) were compared with 91 healthy control subjects (age 14-74) in a case-control design. Patients were matched on age, sex and level of education, with control subjects. Mean interval between injury and cognitive assessment was 13 days. Neurocognitive test battery contained tests of verbal memory, selective attention, general speed of information processing and verbal fluency.

Results: An overall effect was found of a single mild TBI on neurocognitive performance in the sub-acute stage after injury. Age did not add significantly to the effect of mild TBI on cognitive functioning.

Conclusion: Patients suffering from mild TBI are characterized by subtle neurocognitive deficits in the weeks directly following the trauma. The notion that elderly subjects have a worse outcome in the sub-acute period after mild TBI is at least not in line with the results of this study.     

Cognitive training in home environment

Primary objective: To examine the efficacy of cognitive rehabilitation in the patient's home or vocational environment.

Research design: Pre-post-follow-up design.

Methods and procedures: Ten outpatients with acquired attention and memory problems received cognitive training three times weekly, for 3 weeks. They received individual attention training with Attention Process Training, training for generalization for everyday activities and education in compensatory strategies for self-selected cognitive problems. Treatment effects were evaluated with neuropsychological and occupational therapy instruments before and after the training and after 3 months on impairment, activity and participation levels.

Main outcomes and results: The results indicated a positive effect on some measures on impairment level, but no differences on activity or participation levels at follow-up.

Conclusions: The study indicates that home-based cognitive training improves some attentional and memory functions and facilitates learning of strategies. Future controlled studies are needed to confirm the results and analyse the efficacy of different aspects of home-based training.     

Long-term electrophysiological changes in athletes with a history of multiple concussions

Primary objective: This event-related potentials study investigated the long-term effects associated with a history of one or multiple concussions on the N2pc and P3 components using a visual search oddball paradigm.

Methods and procedure: A total of 47 university football players were assigned to three experimental groups based on prior concussion history: Athletes with a history of one concussion (single-concussion group); Athletes with two or more concussions (multi-concussion group); non-concussed athletic controls. The average post-concussion period was 31 months for athletes in the multi-concussion group and 59 months for the single-concussion group.

Results: This study found significantly suppressed P3 amplitude in the multi-concussed athletes group compared to the single-concussion and non-concussed athletes even when using the time since the latest concussion as a covariate.

Conclusion: This finding suggests that the multi-concussed athletes group showed long-lasting P3 amplitude suppression when compared with single-concussion or non-concussed athletes despite equivalent neuropsychological test scores and post-concussion symptoms self-reports. This pattern of results is important because it shows that 'old' concussions do not cause general or ubiquitous electrophysiological suppression. The specificity of the long-term effects of previous concussions to the P3, along with an intact N2pc response, suggests that further work may allow one to pinpoint the cognitive system that is specifically affected by multiple concussions.     

Early and delayed auditory oddball ERPs and brain MRI in patients with MTBI

Introduction: Mild traumatic brain injury (MTBI) is a common neurotraumatologic diagnosis. It is possible to confirm objective cognitive impairment in MTBI patients not only by complex neuropsychological testing but also by event-related potentials (ERPs). The most common ERPs used in clinical practice are based on an oddball paradigm. Magnetic resonance imaging (MRI) is not routinely used in MTBI despite its proven greater sensitivity and specificity in comparison with computer tomography (CT).

Methods: This study investigated 31 MTBI patients and 31 sex and age-matched healthy controls. Both groups underwent clinical neurological examinations. Auditory oddball ERPs and brain MRI were done early after the injury and 3-7 months later.

Results: There were no significant sex, age and education differences between the analysed groups. No significant differences were found in N2 and P3 wave parameters in both ERP examinations.

Conclusion: Standard auditory oddball ERPs are not sensitive enough to detect and/or quantify subtle objective neuropsychological changes in selected MTBI patients, especially those with traumatic MRI brain lesions. More complex auditory or other oddball paradigms have to be tested in the future.     

The Patient Distress Scale questionnaire: factor structure and internal consistency

Primary objective : This study examined the factor structure and internal consistency of the Patient Distress Scale (PDS). The PDS is an 11-item questionnaire that was developed to assess acute neurological patients' awareness of emotional disturbances during early rehabilitation.

Research design : A retrospective cohort of patients seen for inpatient rehabilitation following brain injury.

Procedures : The PDS was administered to patients and family members upon admission to the neurorehabilitation unit as part of their neuropsychological evaluation.

Outcomes and results : Subjects were heterogeneous sample of acute neurological inpatients (n = 84) and their relatives (n = 64). A principle components factor analysis with varimax rotation yielded a three factor solution, which together accounted for 62% of the variance. The factor solution provided partial support for the initial structure of the PDS. Analyses revealed relatively strong reliability coefficients for patients (r = 0.82) and relatives (r = 0.86) on the PDS total score. Acceptable reliability coefficients were also found for patients and relatives on each of the factor scores.

Conclusions : Preliminary findings support the utility of the PDS as a measure of awareness in acute neurological patients.     

Recovery from sports concussion in high school and collegiate athletes

Introduction: Neuropsychological testing is a valuable tool in concussion diagnosis and management. ImPACT, a computerized neuropsychological testing program, consists of eight cognitive tasks and a 21-item symptom inventory.

Method: ImPACT was used to examine the cognitive performance of 104 concussed athletes at baseline, 2, 7 and 14 days post-injury. Dependent measures included composite scores from the ImPACT computerized test battery, as well as a total symptom score from the Post-Concussion Symptom Scale.

Results: Differences between baseline and day 2 post-injury scores were observed for all ImPACT composites (Verbal memory-VERM, visual memory-VISM, processing speed-PROC and reaction time-RT) as well as in total symptom score (SX). At day 7, concussed athletes continued to perform significantly poorer on VERM, VISM, RT and SX. At day 14, only VERM scores were significantly different from baseline.

Conclusions: Cognitive performance deficits in concussed athletes may persist to 7 and even to 14 days in some cases. In addition to symptom status, the athlete's post-concussion cognitive functioning should be considered when making return-to-play decisions.     

The mediating effects of effort upon the relationship between head injury severity and cognitive functioning

Primary objective : Given that poor effort may have a profound impact upon the results of neuropsychological assessment, it is of critical importance that assessment of effort is incorporated into the interpretation of a patient's neuropsychological profile. The current study examines the relationship between head injury severity (as measured by length of post-traumatic amnesia) and level of cognitive functioning in patients passing or failing a test of effort (Test of Malingered Memory).

Research design : A cross-sectional correlational design was employed in a consecutive cohort of 78 persons with ongoing compensation claims.

Methods and procedures : Head injury severity was assessed by duration of post-traumatic amnesia. All participants received a clinical interview followed by neuropsychological assessment.

Main outcomes and results : A systematic and interpretable negative correlation between head injury severity and intellectual and memory functioning was demonstrated in persons passing the test of effort. However, in persons failing the test of effort no such relationships were demonstrated.

Conclusions : The implications for the interpretation of neuropsychological test data are discussed. It is strongly recommend that valid interpretation of neuropsychological assessment data should include consideration of at least one test of effort.     

Motor deficits and recovery during the first year following mild closed head injury

Objective: This study examined motor impairments over 1 year following mild closed head injury (CHI). It is the first study to serially assess long-term oculomotor and upper-limb visuomotor function following mild head trauma.

Methods: Thirty-seven patients with mild CHI and 37 matched controls were compared at 1 week, 3 months and 6 months and 31 available pairs at 12 months post-injury on measures of saccades, oculomotor smooth pursuit, upper-limb visuomotor function and neuropsychological performance. Symptomatic recovery was sampled using the Rivermead Postconcussion Symptoms Questionnaire.

Results: At 1 week, the group with CHI reported high levels of post-concussional symptoms and exhibited prolonged saccade latencies, increased directional errors, decreased saccade accuracy and impaired fast sinusoidal smooth pursuit concomitant with increased arm movement reaction time, decreased arm movement speed and decreased motor accuracy on upper-limb visuomotor tracking tasks. Neuropsychological testing identified deficits only in verbal learning and speed of processing while attention, short-term/working memory and general cognitive performance were preserved. At 3 and 6 months, the group with CHI continued to show deficits on several oculomotor and upper-limb visuomotor measures in combination with some deficits on verbal learning and improved, yet abnormal, levels of post-concussional symptoms. At 12 months, the group with CHI had no cognitive impairment but residual deficits in eye and arm motor function and continued to show elevated levels of post-concussional symptoms.

Conclusions: The findings indicate that multiple motor systems are measurably impaired up to 12 months following mild CHI and that instrumented motor assessment may provide sensitive and objective markers of cerebral dysfunction during recovery from mild head trauma independent of neuropsychological assessment and patient self-report.     

Long-term neuropsychological performance in a cohort of children and adolescents after severe paediatric traumatic brain injury

Objective: The purpose of the present study was to evaluate progress in neuropsychological performance in children and adolescents with severe paediatric traumatic brain injury (TBI), from admission to the rehabilitation centre up to 3-12 years after the trauma.

Methods: Children and adolescents (n = 31, mean age at injury 11.8 years, SD = 3.8; at follow-up 18.8 years; SD = 4.5) who all had suffered a TBI participated. A comprehensive neuropsychological test battery was administered at the start of rehabilitation (T1), around discharge (T2) and in the long-term (at least 3 years after rehabilitation; T3). T1 and T2 were clinical assessments; T3 was executed as a follow-up measurement for this study.

Results: At T1 and T2, most problems were in the domains of attention, memory and executive functioning. At the start of rehabilitation most deficits were with performal intelligence (61%); at discharge (mean length of stay 411 days) considerably less children had severe deficits on the intelligence domain (23%). At long-term follow-up, most problems were in the domains attention, mental speed and memory. From admission to discharge 42% of the children improved on two or more cognitive tests; from discharge to follow-up this percentage was 13%.

Conclusions: In this unique study a clinical cohort of children with severe TBI was followed for many years after injury. Most cognitive deficits were found in the early phase of rehabilitation. Most children did improve on cognitive functioning (40%) during the first year after their injury, whereas at follow-up most children had not changed. At follow-up, more than half of the children (54%) attended a regular school or had a regular job, corresponding to their age and pre-morbid functioning.