Aine Carroll

A study of bone mineral density in adults with disability.

OBJECTIVES To examine prevalence of low bone mineral density (BMD) among adults with disability, using World Health Organization diagnostic categories. DESIGN Cross-sectional study. SETTING National Rehabilitation Hospital, Dublin, Ireland. PARTICIPANTS Patients (N=255; 178 men, 77 women) who were disabled for at least 3 months because of acquired brain injury, spinal cord injury, other neurologic condition, or lower-limb amputation. INTERVENTIONS None. MAIN OUTCOME MEASURES Laboratory investigations including intact parathyroid hormone, 25-hydroxyvitamin D (25-OHD), and sex hormones; and BMD of lumbar spine and at least 1 hip, measured by dual-energy x-ray absorptiometry and expressed as T scores and z scores. RESULTS Mean age +/- SD of participants was 48.7+/-15.6 years. Vitamin D deficiency, 25-OHD level 50 nmol/L or less, occurred in 154 (62.9%); insufficiency, a level between 51 and 72 nmol/L, occurred in 36 (14.7%). Based on T scores, 108 participants (42.4%) had osteopenia, and 60 (23.5%) had osteoporosis. A z score of -1 or less but more than -2 occurred in 76 (29.8%); a further 52 (20.4%) had a z score of -2 or less. On multiple linear regression analysis, ambulatory status and duration of disability were independent predictors of BMD at neck of femur (beta=.152, P=.007; beta=-.191, P=.001, respectively) and total proximal femur (beta=.170, P=.001; beta=-.216, P<.001, respectively). CONCLUSIONS Osteopenia and osteoporosis are very common in adults with disability participating in rehabilitation, compared with the general young adult population. Duration since onset of disability and mobility status are independent predictors of BMD at the hip. Bone health monitoring should form part of the long-term follow-up in adults with newly acquired disabilities.

A prospective randomized controlled study of the role of botulinum toxin in whiplash-associated disorder

Objectives: To investigate the effectiveness of botulinum toxin in preventing the development of chronic whiplash-associated disorder. Design: Prospective, randomized, placebo-controlled double-blind study. Setting: Regional Neurological Rehabilitation Centre with participants being at home. Subjects: Thirty-seven patients with whiplash-associated disorder who remained symptomatic two months after injury. Interventions: Patients were randomized to receive either 250 units botulinum toxin type A (Dysport) or placebo (normal saline). Four trigger points were injected with 0.625 mL of injectant. Outcome measures: Tenderness to palpation scores, visual analogue pain scale, Vernon—Mior Neck Pain and Disability Index and cervical range of motion. Follow-up assessments were carried out at four weeks and three months after treatment. Results: Twenty participants received botulinum toxin and 17 received placebo. Both groups showed a tendency towards improvement in pain scores, Vernon—Mior Index and range of motion at four weeks and three months, with the changes being more pronounced in the toxin group. The change in Vernon—Mior Index in the toxin group was both statistically and clinically significant (i.e. a change of score of ≥5 from baseline to follow-up). Group comparisons did not meet statistical significance. Conclusion: The improvements in outcome measures suggest that botulinum toxin type A may have a role to play in the management of whiplash-associated disorder but larger studies are required to clarify the situation.

Sensorimotor Modulation Assessment and Brain-Computer Interface Training in Disorders of Consciousness

OBJECTIVES To assess awareness in subjects who are in a minimally conscious state by using an electroencephalogram-based brain-computer interface (BCI), and to determine whether these patients may learn to modulate sensorimotor rhythms with visual feedback, stereo auditory feedback, or both. DESIGN Initial assessment included imagined hand movement or toe wiggling to activate sensorimotor areas and modulate brain rhythms in 90 trials (4 subjects). Within-subject and within-group analyses were performed to evaluate significant activations. A within-subject analysis was performed involving multiple BCI technology training sessions to improve the capacity of the user to modulate sensorimotor rhythms through visual and auditory feedback. SETTING Hospital, homes of subjects, and a primary care facility. PARTICIPANTS Subjects (N=4; 3 men, 1 woman) who were in a minimally conscious state (age range, 27-53 y; 1-12 y after brain injury). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Awareness detection was determined from sensorimotor patterns that differed for each motor imagery task. BCI performance was determined from the mean classification accuracy of brain patterns by using a BCI signal processing framework and assessment of performance in multiple sessions. RESULTS All subjects demonstrated significant and appropriate brain activation during the initial assessment, and real-time feedback was provided to improve arousal. Consistent activation was observed in multiple sessions. CONCLUSIONS The electroencephalogram-based assessment showed that patients in a minimally conscious state may have the capacity to operate a simple BCI-based communication system, even without any detectable volitional control of movement.

A qualitative exploration of how individuals reconstruct their sense of self following acquired brain injury in comparison with spinal cord injury

Abstract Primary objective: The present study aimed to investigate the specific ways in which individuals reconstruct their sense of self following injury to the nervous system, by comparing individuals with acquired brain injury (ABI) and individuals with spinal cord injury (SCI), two groups that have experienced a sudden-onset injury with life-changing repercussions. Research design: Phenomenological qualitative research. Methods and procedures: Nine individuals with ABI and 10 individuals with SCI took part in an interview exploring the ways in which individuals reconstruct their sense of self following injury. Data were analysed using interpretative thematic analysis. Main outcomes and results: Findings showed similar themes identified within the interview data of the ABI and SCI groups. Both groups developed positive and negative self-narratives. Individuals employed strategies that facilitated the reconstruction of positive self-narratives. In addition, individuals described their sense of self as simultaneously continuous and changing. Discussion: Findings are discussed in relation to proposed models of self-reconstruction post-injury to the nervous system.

Bone Mineral Density in Adults Disabled Through Acquired Neurological Conditions: A Review

This article is a review of the changes in bone mineral density (BMD), which occur in a number of acquired neurological conditions resulting in disability. For each of spinal cord injury, stroke, multiple sclerosis, Parkinsons disease, and traumatic brain injury, the following aspects are discussed, where information is available: prevalence of low BMD according to World Health Organization diagnostic categories and recommended diagnostic method, prevalence based on other diagnostic tools, comparison of BMD with a control population, rate of decline of BMD following onset of the neurological condition, factors influencing decline; mechanism of bone loss, and fracture rates. The common risk factors of immobilization and vitamin D deficiency would appear to cross all disability groups, with the most rapid phase of bone loss occurring in the acute and subacute phases of each condition.

European models of multidisciplinary rehabilitation services for traumatic brain injury.

McElligott J, Carroll A, Morgan J, Macdonnell C, Neumann V, Gutenbrunner C, Fialka-Moser V, Christodoulou N, Varela E, Giustini A, Delarque A, Assucena A, Lukmann A, Tuulik-Leisi V, Zoltan D: European models of multidisciplinary rehabilitation services for traumatic brain injury. Am J Phys Med Rehabil 2011;90:74Y78.

Alleviating psychosocial issues for individuals with communication impairments and their families following stroke: a case series of interdisciplinary assessment and intervention.

INTRODUCTION A high incidence of depression following a stroke has been reported. Many studies exclude those with communication impairments. However, there is an increased risk of psychosocial issues for individuals with communication difficulties. Psychosocial issues have a significant impact on the individual and their families. There is very limited research in this area. METHODS A retrospective case review of the assessment and intervention with three individuals with significant communication difficulties following stroke was completed. Key interdisciplinary intervention factors were identified. RESULTS Psychosocial issues were identified in all three cases. The assessment of cognitive difficulties, interdisciplinary intervention targeting communication between family members, facilitation of emotional expression and liaison with appropriate community services were identified as key interventions. These interventions targeted at psychosocial issues resulted in a positive outcome for the individuals and their family. DISCUSSION AND CONCLUSION Psychosocial issues are prevalent in individuals and their families with significant communication impairments following stroke. Clinically, these issues may be overlooked. The complexity of working with individuals with cognitive and communication impairments also contributes to poor identification of psychosocial issues. This case series clearly highlights that intervening at the psychosocial level through interdisciplinary working can facilitate meaningful outcomes for the individual and their family.

Cerebral venous thrombosis presenting as a complication of inflammatory bowel disease

Cerebral venous thrombosis is an uncommon and diverse entity accounting for less than 1% of strokes. It can present with a variety of clinical symptoms ranging from isolated headaches to deep coma making the clinical diagnosis difficult. We present a rare case of cerebral venous thrombosis secondary to dehydration and inflammatory bowel disease.

Life expectancy determination

The estimate of life expectancy following a personal injury is probably one of the most important factors in determining the final quantum of damages. It is a calculation fraught with difficulties. This article endeavours to outline some general factors that aid prediction of life expectancy, and also discusses the evidence from the few long-term studies currently available.

Motor Imagery BCI with Auditory Feedback as a Mechanism for Assessment and Communication in Disorders of Consciousness

Patients with disorders of consciousness (DoC) are difficult to assess both because of their unpredictable fluctuation of awareness and the current adopted scales, which have a poor prognostic reliability [1]. Individuals who are in a minimally conscious state (MCS) or vegetative state (VS), or with unresponsive wakefulness syndrome (UWS), may be incapable of providing volitional overt motor responses. This has resulted in a rate of 43% of patients who were diagnosed as having VS being reclassified as MCS after further assessment.