Brian Pentland

Cognitive and psychosocial outcome following moderate or severe traumatic brain injury

The outcome of 96 consecutive adult patients with moderate to severe head injury was sequentially measured at 6, 12 and 24 months post-injury. In addition to global outcome using the Glasgow Outcome Scale (GOS) and a battery of neuropsychological tests of cognitive function, the Head Injury Symptom Checklist (HISC) and Relatives Questionnaire (RQ) were used. Although poorer GOS scores and severe cognitive impairments were typically associated with greater severity of initial injury, relatives reported similar functional problems irrespective of injury severity. This illustrates the legacy of moderate head injury in influencing many aspects of everyday life, supporting the argument that the needs of this group should not be overlooked.

Microcomputer-based attentional retraining after brain damage: A randomised group controlled trial

Abstract Thirty-one patients showing attentional deficits after acute onset brain injury were allocated randomly to two groups; 17 subjects received computerised attentional retraining and 14 received recreational computing. Although there were only minor differences in attentional function at the end of training, by 6-month follow-up the experimental group performed better on two tests related plausibly to attentional function, namely PASAT and the arithmetic subtest of the WAIS-R.

Pain in the Guillain-Barré syndrome: a clinical review

&NA; The Guillain‐Barré syndrome, or acute inflammatory polyneuropathy, is often regarded as a predominantly motor neuropathy with few sensory features, which has a good prognosis in most cases. However, pain is a common symptom occurring in up to 72% of cases. The types of pain are protean including paraesthesiae, dysaesthesia, axial and radicular pain, meningism, myalgia, joint pain and visceral discomfort, etc., and patients may present in a variety of clinical settings such as intensive care units, acute medical wards or rehabilitation departments. These factors, combined with the fact that the condition is relatively uncommon, means that no controlled trial of pain management has been done and a range of treatments has been proposed. We review the various pains which may be associated with Guillain‐Barré syndrome and discuss suggestions for their management.

Fluoxetine as a treatment for emotional lability after brain injury

Emotional lability or emotionalism is a relatively common phenomenon and frequently occurs following vascular or traumatic brain injury. It is distressing and embarrassing to sufferers and their families, and often interferes with rehabilitation. At present there is no satisfactory or reliable treatment for this condition. We describe an open trial using fluoxetine, a newer antidepressant with a specific serotonergic action, in the treatment of emotional lability due to brain injury. Six consecutive cases of emotional lability attending a rehabilitation unit were studied (five cases of cerebrovascular accident and one of traumatic brain injury). Response to treatment was measured using a modification of the scale described by Lawson and MacLeod [1]. All showed a marked improvement within one week of commencing fluoxetine and the drug was well tolerated with no reported side-effects. The speed of onset and degree of improvement suggest that fluoxetine may be a useful agent in the treatment of emotional lability due to brain injury. Our observations indicate that further investigation of the role of fluoxetine in the treatment of emotional lability is warranted.

Use of the functional assessment measure (FIM+FAM) in head injury rehabilitation: a psychometric analysis

OBJECTIVES The drive to measure outcome during rehabilitation after brain injury has led to the increased use of the functional assessment measure (FIM+FAM), a 30 item, seven level ordinal scale. The objectives of the study were to determine the psychometric structure, internal consistency, and other characteristics of the measure. METHODS Psychometric analyses including both traditional principal components analysis and Rasch analysis were carried out on FIM+FAM data from 2268 assessments in 965 patients from 11 brain injury rehabilitation programmes. RESULTS Two emergent principal components were characterised as representing physical and cognitive functioning respectively. Subscales based on these components were shown to have high internal consistency and reliability. These subscales and the full scale conformed only partially to a Rasch model. Use of raw item ratings, as opposed to transformed ratings, to produce summary scores for the two subscales and the full scale did not introduce serious distortion. CONCLUSION The full FIM+FAM scale and two derived subscales have high internal reliability and the use of untransformed ratings should be adequate for most clinical and research purposes in comparable samples of patients with head injury.

Parkinson’s disease and driving ability

Objectives: To explore the driving problems associated with Parkinson’s disease (PD) and to ascertain whether any clinical features or tests predict driver safety. Methods: The driving ability of 154 individuals with PD referred to a driving assessment centre was determined by a combination of clinical tests, reaction times on a test rig and an in-car driving test. Results: The majority of cases (104, 66%) were able to continue driving although 46 individuals required an automatic transmission and 10 others needed car modifications. Ability to drive was predicted by the severity of physical disease, age, presence of other associated medical conditions, particularly dementia, duration of disease, brake reaction, time on a test rig and score on a driving test (all p<0.001). The level of drug treatment and the length of driving history were not correlated. Discriminant analysis revealed that the most important features in distinguishing safety to drive were severe physical disease (Hoehn and Yahr stage 3), reaction time, moderate disease associated with another medical condition and high score on car testing. Conclusions: Most individuals with PD are safe to drive, although many benefit from car modifications or from using an automatic transmission. A combination of clinical tests and in-car driving assessment will establish safety to drive, and a number of clinical correlates can be shown to predict the likely outcome and may assist in the decision process. This is the largest series of consecutive patients seen at a driving assessment centre reported to date, and the first to devise a scoring system for on-road driving assessment.

Impressions of parkinsonian patients from their recorded voices

The voices of patients suffering from Parkinsons disease change in various ways. This paper sets out to examine the effect of these changes on the impressions made on listeners, and to try to see what vocalic and prosodic features account for these impressions. Tape recordings from segments of interviews with 4 patients, and 4 control subjects with ischaemic heart disease, were played to 16 naive listeners. These listeners were asked to rate their impressions of these voices on 15 dimensions of personality. There were significant differences on most of the dimensions, despite the fact that there were no differences between the two groups on such scales as Becks depression inventory and the mood adjective check list. The parkinsonian patients were seen to be cold, withdrawn and anxious, not to relate well to the interviewer and to be enjoying the interview less than the controls. These ratings are very similar to those previously reported for the same patients, using silent video recordings only. The voice recordings were analysed along various dimensions of prosody. The factors which were different between the groups included the frequency and type of pauses in speech and the range or variability of the fundamental frequency. The implications of this exploratory study for intervention are discussed.

Depression and anxiety symptoms after lower limb amputation: the rise and fall

Objective: To examine the time course of anxiety and depressive symptoms over a three year period after amputation. Design and settings: A prospective study in inpatients admitted to a rehabilitation ward after lower limb amputation. Subjects: Successive admissions over a one-year period of whom 68 were alive at follow-up, 2—3 years later. Interventions: Nil. Main measures: Hospital Anxiety and Depression Scale (HADS) on admission and discharge from inpatient rehabilitation and at a 2.7(SD=0.4) year mean follow-up period with correlation to demographic and patient features. Results: Of the 68 responding patients, 12 (17.6%) and 13 (19.1%) had symptoms of depression and anxiety respectively. This compared to an original incidence of 16 (23.5%) for both on admission and 2 (2.9%) on discharge. This rise in incidence from time of discharge was highly significant for both depression (P<0.001) and anxiety (P<0.001). Depression at follow-up was correlated to depressive symptoms at admission (P=0.03) and to having other significant comorbidities (P=0.02). Anxiety symptoms were commoner in younger patients (P=0.03). There was no association with age, gender, living in isolation, vascular cause for amputation, wearing a limb prosthesis or length of original inpatient stay. Conclusions: Depression and anxiety are common after lower limb amputation but resolve during inpatient rehabilitation. The incidence then rises again after discharge.

The effects of reduced expression in Parkinson's disease on impression formation by health professionals

The first impressions formed by 91 therapists shown silent videorecordings of four patients with idiopathic Parkinsons disease and four with ischaemic heart disease were assessed using visual analogue scales directed at aspects of mood, personality and intellect. Although both patient groups showed no abnormalities in terms of affect, personality and intelligence by standardised psychological tests, the Parkinsonian patients appeared more anxious, hostile, suspicious, unhappy, bored and tense than the cardiac cases; they came across as less intelligent, more introverted and passive, less stable and tough minded; they seemed to enjoy and maintain their part in the conversation less well and relate less to the interviewer and overall they were rated as less likeable. These findings are related to the known effects of speech impairment on impression formation in Parkinsons disease and are discussed in terms of the possible effects on therapeutic relationships and their bearing on diagnosis of psychiatric disturbance in the condition.

Cotard delusion after brain injury

A right-handed young man with contusions affecting temporo-parietal areas of the right cerebral hemisphere and some bilateral frontal lobe damage became convinced that he was dead (the Cotard delusion), and experienced difficulties in recognizing familiar faces, buildings and places, as well as feelings of derealization. Neuropsychological investigation while these symptoms were resolving revealed impairment on face processing tests. We suggest that these impairments contributed to his Cotard delusion by heightening feelings of unreality, and that the underlying pathophysiology and neuropsychology of the Cotard delusion may be related to other problems involving delusional misidentification.