Mark Delargy

Locked-in syndrome

The locked-in syndrome is caused by an insult to the ventral pons, most commonly an infarct, haemorrhage, or trauma. The characteristics of the syndrome are quadriplegia and anarthria with preservation of consciousness. Patients retain vertical eye movement, facilitating non-verbal communication. Ten year survival rates as high as 80% have been reported. Even limited physical recovery can improve quality of life and enable patients to return to live with their families. Early referral to a specialist rehabilitation service for specialist care and technology is therefore important. We gathered information for this article through searches in Medline and Taylor and Francis Health Sciences, identifying relevant case series reviews on the locked-in syndrome and other brain stem strokes. Our own experience is also incorporated. Locked-in syndrome was first defined in 1966 as quadriplegia, lower cranial nerve paralysis, and mutism with preservation of consciousness, vertical gaze, and upper eyelid movement.1 It was redefined in 1986 as quadriplegia and anarthria with preservation of consciousness.2 This redefinition served to clarify that mutism could imply unwillingness to speak.3 Although patients are conscious, attention, executive function, intellectual ability, perception, and visual and verbal memory can be affected.4 Leon-Carrion and colleagues reviewed 44 patients with the locked-in syndrome, of whom eight reported memory problems and six attentional deficits.5 Memory difficulties were more likely when the aetiology was traumatic.5 However, in a report of two patients with chronic locked-in syndrome, neuropsychological assessment showed preserved cognitive abilities.6 A review by Zeman of consciousness indicated that cerebral metabolism, as monitored by positron emission tomography, is only mildly reduced in locked-in syndrome but severely reduced in the vegetative state.7 The electroencephalogram typically shows slow wave activity in the vegetative state but normal activity in locked-in syndrome. Anarthria is due to bilateral facio-glosso-pharyngo-laryngeal paralysis,8 which …

Emotional distress and awareness following acquired brain injury: An exploratory analysis

Background: Symptoms of depression and anxiety are commonly reported following brain injury, providing ongoing challenges to patients, clinicians and carers. There is increasing interest in the influence of impaired awareness on emotional distress, supported by psychological investigations. Objective: To explore the relationship between awareness and time since injury on reported emotional distress. Method: Awareness was assessed by comparing the reports of persons with brain injury to the reports of their treating clinicians and significant others. Fifty-four participants with acquired brain injury (ABI) completed the Awareness Questionnaire, the Dysexecutive Questionnaire and the Hospital Anxiety and Depression Scales. Clinicians and significant others completed the Awareness Questionnaire and the Dysexecutive Questionnaire in relation to each participant. Results: Analyses of variance identified a main effect of awareness, such that participants with better awareness of their difficulties had higher emotional distress, regardless of time since injury. Conclusion: Findings support psychological theories suggesting that emotional distress is a response to the stressor of a brain injury and denial of difficulty, manifesting as impaired awareness, may play a protective role. They highlight the importance of understanding a patients level of awareness so as to provide support aimed at minimizing the impact of distress on the rehabilitation outcome.

The contribution of retrospective memory, attention and executive functions to the prospective and retrospective components of prospective memory following TBI

Primary objective: Despite the prevalence of prospective memory (PM) problems, relatively little is known about the processes underlying impairment following TBI. This study sought to examine PM performance, using a multiple-task, multiple-response video-based paradigm in which initial encoding of the cue-action associations was ensured (Video-Assessment of Prospective Memory; VAPM). Research design: VAPM was designed to allow easy identification of reasons for failure (i.e. cue detection and/or specific action retrieval). Patients with moderate/severe TBI (n = 32) and matched controls (n = 16) also completed standardized neuropsychological assessment including evaluation of episodic retrospective memory (RM), attention, information processing, executive functions and mood. Main outcomes and results: As a group, those with TBI were impaired on PM tasks with 50% failing to complete at least 2/6 required tasks despite near perfect performance by controls. Individual profile analyses revealed different reasons for impairment, with RM contributing significantly to both the prospective and retrospective components. This was supported by correlational analyses illustrating a significant relationship between cue detection and RM measures, in addition to measures of executive functions and attention. Conclusions: The contribution of RM to both components of PM, along with the finding of heterogeneity in performance among participants have important implications for theoretical understanding and clinical practice.

Quadriplegic care: An assessment of the impact on the carer

Thirty-three voluntary carers living with dependent quadriplegics completed a questionnaire survey which recorded their views on the assistance they received. Disruption to sex life, wheelchair restrictions, personality change in the quadriplegic person, and problems with bladder care were the features they most disliked. We have introduced a self-help group. Respite care would assist them with the valuable service they provide at considerable personal cost.

Late multidisciplinary rehabilitation in young people after stroke

Purpose: Stroke has a major impact on physical and cognitive ability, and quality of life. This study aims to examine the effect of multidisciplinary rehabilitation on outcome in an Irish young stroke population. Method: Fifty consecutive patients younger than 65 were prospectively recruited to this observational study. Physical and cognitive ability, and quality of life were measured on admission and discharge. Results: All patients were transferred to the rehabilitation unit from the acute hospital where they had received their initial management. Median length of time from stroke onset to transfer was 112 days. After a median of 70 days, 43 patients were discharged home. Patients made significant gains in physical (Barthel index 12 to 18) and cognitive ability (mini-mental state examination 22 to 25). Quality of life improved in all eight domains of the 36-item Short Form with four domains returning to levels seen in the general population. Conclusions: This study documents the improvements in physical and cognitive abilities, and quality of life in a sample of patients in rehabilitation. A comprehensive rehabilitation programme that includes acute and late multidisciplinary phases can improve the outcome of patients following stroke.

Barriers and facilitators associated with return to work after stroke: a qualitative meta-synthesis

Abstract Purpose: To enhance the employment outcomes of individuals who experience a stroke, it is essential to understand the factors that determine successful return to work. The aim of this systematic review was to examine barriers to and facilitators of return to work after stroke from the perspective of people with stroke through the process of a qualitative meta-synthesis. Methods: A systematic literature search was conducted. Studies that employed qualitative methods to explore the experiences of individuals with stroke around return to work after stroke were included. The methodological quality of the studies was assessed by two independent reviewers. Overarching themes, concepts and interpretations were extracted from each individual study, compared and meta-synthesized. Results: Fifteen studies were included and the overall methodological quality of the studies was good. Four broad themes emerged as factors associated with return to work after stroke. These included (i) the nature of the effects of stroke, (ii) the preparatory environment, (iii) personal coping strategies and internal challenges and (iv) the meaning of work. Conclusion: Return to work after stroke is a complex process which can be facilitated or impeded by organizational, social or personal factors, as well as accessibility to appropriate services. Implications for Rehabilitation Following a period of dedicated inpatient rehabilitation, there is a need to integrate community-support services to optimize return to work among stroke survivors. A dedicated community stroke support liaison officer may help to facilitate the transition between the hospital and the community and workplace environment. Education provided by healthcare professionals is necessary in the community and the workplace to ensure that family, friends and employers are aware of the impairments, activity limitations and participation restrictions of the stroke survivor.

Impaired self-awareness after traumatic brain injury: inter-rater reliability and factor structure of the Dysexecutive Questionnaire (DEX) in patients, significant others and clinicians.

Aims: This study sought to address two questions: (1) what is the inter-rater reliability of the Dysexecutive Questionnaire (DEX) when completed by patients, their significant others, and clinicians; and (2) does the factor structure of the DEX vary for these three groups? Methods: We obtained DEX ratings for 113 patients with an acquired brain injury from two brain injury services in the UK and two services in Ireland. We gathered data from two groups of raters—“significant others” (DEX-SO) such as partners and close family members and “clinicians” (DEX-C), who were psychologists or rehabilitation physicians working closely with the patient and who were able to provide an opinion about the patient’s level of everyday executive functioning. Intra-class correlation coefficients and their 95% confidence intervals were calculated between each of the three groups (self, significant other, clinician). Principal axis factor (PAF) analyses were also conducted for each of the three groups. Results: The factor analysis revealed a consistent one-factor model for each of the three groups of raters. However, the inter-rater reliability analyses showed a low level of agreement between the self-ratings and the ratings of the two groups of independent raters. We also found low agreement between the significant others and the clinicians. Conclusion: Although there was a consistent finding of a single factor solution for each of the three groups, the low level of agreement between significant others and clinicians raises a question about the reliability of the DEX.

Self-awareness following acquired brain injury: measurement and relationship to executive functioning

Impaired self-awareness (ISA) is common following acquired brain injury (ABI) and is related to functional outcome variables. This study examines two questionnaires currently used in clinical and research settings, which measure ISA by comparing patient reports with those of clinicians and significant others. This study also attempts to identify sensitive neuropsychological tests which may be used to predict ISA. A multivariate cross-sectional design is employed, including regression analyses and correlations. Fifty-four participants with ABI completed the Awareness Questionnaire (AQ), the Dysexecutive Questionnaire (DEX) and a battery of neuropsychological tests. Clinicians and significant others of each participant completed the AQ and the DEX. Findings support convergent validity of the two questionnaires; however, there were differences in the response patterns on each questionnaire. Regression analyses indicated that estimated IQ and in particular verbal IQ scores accounted for a greater amount of th...