Agnes Shiel

Errorless learning in the rehabilitation of memory impaired people

Abstract We report six experiments comparing errorful and errorless learning in the teaching of new information to neurologically impaired adults with severe memory problems. The first experiment is a group study in which amnesic subjects, young controls, and older controls were required to learn two lists of words under two conditions. One of these required subjects to generate guesses that produced incorrect responses, and the other prevented guessing—permitting only correct responses. Conditions and lists were counterbalanced across subjects. People with amnesia scored significantly higher under the errorless condition. We further explored the principle of errorless learning in five single case studies in which severely memory impaired people were required to learn information analogous to that needed in everyday life. Tasks included learning names of objects and people, learning how to programme an electronic aid, remembering orientation items, and learning new items of general knowledge. In each case...

Auditory sustained attention is a marker of unilateral spatial neglect

The relationships between performance on a non-spatially-lateralized measure of sustained attention and spatial bias on tests sensitive to unilateral neglect were considered in a group of 44 patients with right hemisphere lesions following stroke. As predicted from earlier studies showing a strong association between unilateral spatial neglect and sustained attention, performance on a brief and monotonous tone-counting measure formed a significant predictor of spatial bias across a variety of measures of unilateral visual neglect. This study provides further evidence for a very close link between two attentional systems hitherto regarded as being quite separate, namely a spatial attention system implicated in unilateral neglect and a sustained attention system. A close connection between these two systems was predicted by Posner, who argued that the right hemisphere-dominant sustained attention system provides a strong modulatory influence on the functioning of the lateralized posterior attention system.

The Wessex Head Injury Matrix (WHIM) main scale: a preliminary report on a scale to assess and monitor patient recovery after severe head injury:

Objective: To develop a behavioural assessment based on observations of patients recovering after severe head injury whereby data could be collected by observation and by testing everyday tasks. Design: A prospective observational study of a cohort of 88 consecutive hospital admissions with severe head injury. Setting: Two district general hospitals in the UK. Patients: Eighty-eight consecutive admissions with severe traumatic head injury. Ages ranged from 14 to 67 years, mean coma duration was 14 days and mean duration of post traumatic amnesia (PTA) was 56 days. Results: Fifty-eight items of behaviour were identified. Paired preference analysis was used to identify a sequence of recovery of these behaviours. The sequence began with arousal and led on to behaviours signalling recovery of social interaction and communication. Subsequent behaviours indicated increasing cognitive organization and return of orientation and memory. The behaviours on the scale are hierarchical and range from coma to emergence from PTA. Conclusions: A scale to assess patients and monitor cognitive recovery after severe head injury has been developed. While individual patients will show some departures from the sequence identified, the scale helps to make explicit the earliest stages of natural recovery patterns after head injury.

The effects of increased rehabilitation therapy after brain injury: results of a prospective controlled trial:

Objective: The objective was to investigate the effect of increased intensity of rehabilitation therapy provided to brain-injured subjects on the rate at which independence was regained and the duration of hospital admission. Design: A two-centre, prospective, controlled study with random allocation to groups. Setting: Two district general hospitals on the south coast of England. Subjects: Fifty-six people with moderate and severe head injury consecutively admitted to Southampton and Poole hospitals between June 1995 and September 1997. Interventions: Increased intensity of rehabilitation therapy input without change in content. Results: Subjects receiving more intensive therapy made more rapid progress and were discharged home sooner. The different intensities of therapy employed in this study showed no evidence of a ‘ceiling’ effect and the ‘intervention group’ made significantly more rapid progress on tests of dependency during the period of admission. A clear response to increased therapy input was seen in one of the centres with more rapid functional improvement and a shorter length of hospital stay. This centre already had more therapy and better community facilities. No such benefits were seen at the other centre where the intervention group had a longer hospital stay than the routine group. Conclusion: Increasing the hours per week of therapy given to adults recovering from brain injury in hospital can accelerate the rate of recovery of personal independence and result in their being discharged from hospital sooner. Increased rehabilitation therapy after brain injury is associated with enhanced functional recovery and shorter hospital stay if provided in the context of an integrated service that can provide ongoing community support. There is no evidence of any ceiling effect of therapeutic intensity beyond which no further response is observed.

Long-term retention deficits in two cases of disproportionate retrograde amnesia

The status of very long-term retention, together with detailed brain imaging correlates, is presented in two patients with disproportionately dense retrograde amnesia. The first patient suffered a severe closed head injury and was left with dense autobiographical amnesia for events that she had experienced prior to her injury. She showed relatively mild, patchy memory impairment on standard anterograde memory tests. Postinjury autobiographical memory was relatively spared. However, postinjury long-term knowledge acquisition was significantly impaired. The second patient also suffered a severe head injury and was left with marked retrograde amnesia for events that she had experienced prior to her injury. She also showed relatively mild, patchy impairment on standard anterograde memory tests. Using specially designed tests, this patient showed normal immediate learning and delayed recall using a range of materials, but displayed significantly faster rate of forgetting over a period of 6 weeks than control subjects who were matched on initial delayed levels of retention. In both cases, there was major pathology in the region of the left temporal lobe, with lateral structures being more affected than medial structures. Our findings provide further evidence relating to the independence of certain anterograde and retrograde memory mechanisms, and support recent observations (De Renzi & Lucchelli, 1993) that link some instances of retrograde amnesia to impairment in very long-term retention. The possibility is raised that some forms of retrograde amnesia, such as the present cases, represent a type of disconnection syndrome, whereby visual-semantic and other associations are disconnected from verbal representations of such associations. Lesions to intrahemispheric fasciculi or similar association fibers, in combination with lesions to critical anterior or posterior cerebral structures, may play an important role in such a disconnection.

Effect of posture on levels of arousal and awareness in vegetative and minimally conscious state patients: a preliminary investigation

Moderate to severe brain injury is estimated to occur in 25 individuals per 100 000 population every year. Of these, 10–20% never fully regain consciousness but remain in a vegetative or minimally conscious state.1 Patients in the vegetative state may appear at times to be wakeful, with cycles of eye closure and eye opening resembling those of sleep and waking, but show no sign of awareness or of a functioning mind.2 In contrast, patients considered to be in a minimally conscious state are said to show inconsistent but definite evidence of awareness despite profound cognitive impairment.3 At present, the pathophysiology underlying the vegetative and minimally conscious states is unclear, a standard treatment approach is lacking, and very little has been discovered to advance rehabilitation techniques. It is widely acknowledged that active rehabilitation should begin …

Wessex Head Injury Matrix and Glasgow/Glasgow-Liege Coma Scale: A Validation and Comparison Study

The Wessex Head Injury Matrix (WHIM) is an assessment tool designed for use during and immediately after coma. The aim of this study was (1) to test a French adaptation of the WHIM, (2) to compare the WHIM to the Glasgow Coma Scale (GCS) and its extension, the Glasgow-Liège Coma Scale (GLS), and (3) to confirm the sequence of emergence of behaviours. The three scales were used to assess 23 patients admitted to an intensive care unit with a GCS score equal to or less than 8 for at least 1 hour, longitudinally. Results indicated that the WHIM had good concurrent validity with the GCS and GLS, good inter-rater agreement, and excellent test-retest reliability. The WHIM is more appropriate and sensitive than the GCS and the GLS for the period of emerging from coma and immediately afterwards, whereas the GLS is more appropriate than the WHIM for the deepest phase of coma, as it also assesses brainstem reflexes. Furthermore, analysis of our data confirmed the ordering of the 66 items of the WHIM as a function of sequence of recovery from coma, as suggested by its authors.

The impact of traumatic brain injury on family members living with patients: a preliminary study in Japan and the UK

PURPOSE To ascertain the views of families living with TBI patients about the nature of the problems experienced as a result of TBI, and to compare the views of Japanese family members (J-FM) and British family members (B-FM) in order to find out whether there were cultural differences in family response to TBI. METHODS Family members involved in providing care were identified by the patients. Face to face interviews were conducted with all 18 carers in B-FM and four carers in J-FM. The remaining eight carers in J-FM participated in the postal questionnaire. Questionnaires were developed to explore the nature of problems and the involvement of family such as social embarrassment. RESULTS Problems arising in families were almost the same reported from both groups. However families in B-FM were likely to know more about how to cope with these problems. Family members in J-FM reported more statistically significant increases in social embarrassment than those in B-FM. CONCLUSION The preliminary results showed that family members living with TBI patients in both groups had experienced problems. Appropriate rehabilitation services should be developed to help families as well as TBI patients in Japan.Purpose: To ascertain the views of families living with TBI patients about the nature of the problems experienced as a result of TBI, and to compare the views of Japanese family members (J-FM) and British family members (B-FM) in order to find out whether there were cultural differences in family response to TBI. Methods: Family members involved in providing care were identified by the patients. Face to face interviews were conducted with all 18 carers in B-FM and four carers in J-FM. The remaining eight carers in J-FM participated in the postal questionnaire. Questionnaires were developed to explore the nature of problems and the involvement of family such as social embarrassment. Results: Problems arising in families were almost the same reported from both groups. However families in B-FM were likely to know more about how to cope with these problems. Family members in J-FM reported more statistically significant increases in social embarrassment than those in B-FM. Conclusion: The preliminary results showed that family members living with TBI patients in both groups had experienced problems. Appropriate rehabilitation services should be developed to help families as well as TBI patients in Japan.

An evaluation of neurobehavioural problems as perceived by family members and levels of family stress 1–3 years following traumatic brain injury in Japan

Objective: To ascertain the proportion of patients with traumatic brain injury (TBI) admitted to a Japanese district hospital and to evaluate the levels of stress and anxiety in families living with those TBI patients. Design: A retrospective study of patients admitted to hospital from April 1995 to March 1997 and a questionnaire study of family members of survivors. Setting and subjects: All patients referred or transferred to the Emergency Department at the Saga Medical School Hospital, Japan with a primary diagnosis of TBI were studied. Family members living with TBI patients were sent questionnaires. Main outcome measures: The Barthel Index, the Patient Competency Rating Scale, the modified Caregiver Strain Index and the Hospital Anxiety and Depression Scale. Results: There were 34 patients who required hospitalization for care relating to TBI. Of these, nine family members took part in the questionnaire study. Three carers reported fairly high levels of stress and another three carers were considered to be at risk of anxiety and depression. There was a tendency for family members who reported that patients had difficulties in performing behavioural tasks to have higher levels of stress themselves. Conclusion: These preliminary results showed that family members experienced certain levels of stress and were also at risk of anxiety and depression. The impact of TBI on families as well as patients should receive more attention.

Assessment after extremely severe head injury in a case of life or death : further support for McMillan

This paper is a sequel to that of McMillan (1997) and describes further assessment of an extremely severely head injured patient. A combination of direct observations, structured interviews with staff, simple cognitive tests and questions with yes/no answers were used to assess communication and cognitive function in an extremely severely head injured patient with minimal ability to respond. Results confirmed the finding of McMillan and showed that the patient could understand and respond consistently to simple commands, could answer simple autobiographical questions consistently and clearly expressed her wish to live. The results of this study and that of McMillan confirm that valid assessment of minimally responsive patients is possible and that a number of different approaches are appropriate.