Systemic and cerebral hemodynamics during cognitive testing

OBJECTIVE

Cognitive deficits are reported in 10-60% of individuals with SCI, the primary etiology of these deficits is believed to be concomitant traumatic brain injury (TBI). We recently documented diminished memory and marginally deficient attention and processing speed in individuals with SCI discordant for hypotension but matched for TBI.

METHODS

Twenty-nine individuals participated: 16 non-SCI controls, 6 paraplegic (T2-T10) and 7 tetraplegic (C4-C8). The Stroop test was used to measure cognitive function and transcranial Doppler ultrasound was used to measure cerebral blood flow (CBF) while resting (5 min) and continuously during cognitive testing. Mean arterial pressure (MAP) was calculated from three brachial blood pressures and cerebral vascular resistance index was calculated as: CVRi = MAP/CBF.

RESULTS

The paraplegia group (54 ± 6) was marginally older than the non-SCI (42 ± 15; p = 0.06) and tetraplegic (42 ± 11; p = 0.09) groups. Compared to non-SCI group, normalized t-score on the Stroop Color (SC) task was significantly lower in the paraplegic group (p < 0.05). In the tetraplegic group, MAP was significantly lower (p < 0.05) than the non-SCI and paraplegic groups, and related to SC t-score (r (2) = 0.873; p < 0.01). In the paraplegic group, CBF was reduced (p < 0.05) and CVRi increased (p < 0.05) compared to the non-SCI group, and CVRi was increased compared to the tetraplegic group (p < 0.05). A significant inverse relationship was noted between change in CVRi and SC t-score in the non-SCI group.

CONCLUSION

Asymptomatic hypotension relates to cognitive performance in persons with tetraplegia; therefore, BP normalization should be considered. The inappropriate cerebral vascular response to cognitive testing and poor test performance should be investigated in persons with paraplegia.

Factors associated with motor speech control in children with spastic cerebral palsy

BACKGROUND

Speech production is often impaired in children with cerebral palsy (CP). This study investigated the factors associated with motor speech control in children with spastic cerebral palsy.

METHODS

Thirty-three children with spastic CP who were able to speak were identified for this study. They were classified into two groups: group A (spastic diplegia or hemiplegia, n = 17) and group B (spastic quadriplegia, n = 16). Each child received various assessments, namely cognition, language, modified Verbal Motor Production Assessment for Children (VMPAC), speech intelligibility, CP subtype, and Gross Motor Function Classification System (GMFCS).

RESULTS

Group A showed better cognition and language function, higher modified VMPAC scores and better GMFCS levels than group B (p < 0.05). However, the two groups did not significantly differ in speech intelligibility. Linear regression indicated that all modified VMPAC scores were negatively related to CP subtype (adjusted r2 = 0.51~0.63, p < 0.001). The average modified VMPAC scores had a positive relationship with global language scores (adjusted r2 = 0.63, p < 0.001), and the modified VMPAC scores of the sequence subtests were positively related to the full intelligence quotients (adjusted r2 = 0.55, p < 0.001).

CONCLUSION

The findings of this study suggest that motor impairment severity, cognition and language functions are associated with the motor speech control among children with CP.

Sleep in disorders of consciousness

From a behavioral as well as neurobiological point of view, sleep and consciousness are intimately connected. A better understanding of sleep cycles and sleep architecture of patients suffering from disorders of consciousness (DOC) might therefore improve the clinical care for these patients as well as our understanding of the neural correlations of consciousness. Defining sleep in severely brain-injured patients is however problematic as both their electrophysiological and sleep patterns differ in many ways from healthy individuals. This paper discusses the concepts involved in the study of sleep of patients suffering from DOC and critically assesses the applicability of standard sleep criteria in these patients. The available literature on comatose and vegetative states as well as that on locked-in and related states following traumatic or non-traumatic severe brain injury will be reviewed. A wide spectrum of sleep disturbances ranging from almost normal patterns to severe loss and architecture disorganization are reported in cases of DOC and some patterns correlate with diagnosis and prognosis. At the present time the interactions of sleep and consciousness in brain-injured patients are a little studied subject but, the authors suggest, a potentially very interesting field of research.

The subjective brain, identity, and neuroethics

The human brain is subjective and reflects the life of a being-in-the-world-with-others whose identity reflects that complex engaged reality. Human subjectivity is shaped and in-formed (formed by inner processes) that are adapted to the human life-world and embody meaning and the relatedness of a human being. Questions of identity relate to this complex and dynamic reality to reflect the fact that biology, human ecology, culture, and one's historic-political situation are inscribed in one's neural network and have configured its architecture so that it is a unique and irreplaceable phenomenon. So much is a human individual a relational being whose own understanding and ownership of his or her life is both situated and distinctive that neurophilosophical conceptions of identity and human activity that neglect these features of our being are quite inadequate to ground a robust neuroethics.

Use of safe-laser access technology to increase head movement in persons with severe motor impairment: A series of case reports

The purpose of this article is to describe the impact of an intervention involving safe-laser pointing technology on six persons with locked-in syndrome. When these individuals were invited to participate in this project (4 weeks to 18 years post onset), none were able to speak and none were able to access an augmentative and alternative communication (AAC) device. All communicated using eye movements (e.g., looking up or down), eye blinks, dependent scanning strategies with eye movement signals, or eye linking. Following intervention with the Safe-Laser Access System, three of the six participants developed head movement sufficient to control AAC technology. Two participants continue to develop head control; however, their progress has been slowed by repeated illnesses. One participant has discontinued his involvement with the project because of medical and psychological concerns. These six participants represent consecutive referrals to the project.

Behavioural treatment of non-compliance in adolescents with newly acquired spinal cord injuries

PURPOSE

To demonstrate the efficacy of using differential reinforcement to treat non-compliance in adolescents with spinal cord injury.

METHOD

A case series design was used to examine three adolescents (aged 14-16 years) with tetraplegia who received multi-disciplinary rehabilitation treatment and a behavioural contract programme during an in-patient hospital admission. Assessment included collecting data on each patient's weekly percentage of compliance with all rehabilitation goals, weekly percentage of negative affect observed in therapy sessions and scores on a measure of mobility in physical therapy.

RESULTS

Compliance with rehabilitation demands improved from a baseline of 20-65% to 80% or greater after the patients received differential reinforcement for participating in the rehabilitation regimen. Patients exhibited less anger, sadness and frustration during therapy sessions once contracts were started.

CONCLUSIONS

The adolescents demonstrated greater compliance after the implementation of a behavioural contract. Future studies should identify the specific variables that affect psychological adjustment and predict 'readiness' to participate in rehabilitation.

What promotes physical activity after spinal cord injury? An interview study from a patient perspective

PURPOSE

Physical activity in people with traumatic spinal cord injury (SCI) is of importance not only for maintaining health but also for increasing the possibilities of living an independent life. Physical inactivity leads to poorer muscular and cardiovascular conditioning and sub-optimal levels of functioning. To help people with SCI to achieve optimum physical activity, it is important to understand what promotes the incorporation of regular physical activity into daily life. The aim of this study was thus to identify factors that may promote participation in physical activity among people with spinal cord injuries.

METHOD

Qualitative multiple case studies. Sixteen participants with SCI were interviewed.

RESULT

Four main themes of promoting factors could be identified. They were: using cognitive and behavioural strategies; finding supporting environmental solutions; exploring motivation post injury; and capturing new frames of reference.

CONCLUSION

By utilising the motivational power of role models, together with the other motivational factors identified in this study, such as identifying relevant individual motives post injury and capturing new frames of reference, the process towards physical active life may be facilitated.

Home literacy predictors of early reading development in children with cerebral palsy

The goal of the present 1-year long longitudinal study was to determine which home literacy variables were effective in stimulating early reading skills of children with cerebral palsy (CP) directly or indirectly via the reading precursors. Parents of 35 children with CP completed questionnaires regarding aspects of the home literacy environment (HLE). The reading precursors: Vocabulary, Syntactic skills and phonological awareness, i.e., Rhyme and Phonemic awareness, were assessed at the end of Kindergarten and the end of Grade 1, while the early reading skills Letter knowledge and Word recognition were assessed only at the end of Grade 1. Three HLE variables were found to be related to reading precursors and early reading skills: Parent literacy mediation, Word orientation and Story orientation activities during shared book reading. Path analyses showed that these three HLE variables were not directly related to early reading skills in Grade 1, but indirectly via the reading precursors, in particular phonological awareness.

Three persons with multiple disabilities accessing environmental stimuli and asking for social contact through microswitch and VOCA technology

BACKGROUND

Direct access to environmental stimuli and opportunity to ask for social contact/attention may be considered highly relevant objectives for persons with multiple disabilities. We assessed the possibility of enabling three of these persons (two children and one adolescent) to combine two microswitches (for accessing environmental stimuli) and a Voice Output Communication Aid (VOCA), which allowed them to ask for caregiver's attention.

METHODS

Initially, the participants were required to use each of the two microswitches individually and then together. Thereafter, they were taught to use the VOCA. Eventually, the VOCA was available together with the microswitches, and the participants could use any of the three.

RESULTS

The results, which support preliminary data on this topic, showed that all participants (1) were able to operate the two microswitches as well as the VOCA; and (2) used all three of them consistently when they were simultaneously available.

CONCLUSIONS

Teaching persons with multiple disabilities to combine a VOCA with conventional microswitches may enrich their general input, emphasize their active social role and eventually enhance their social image.

Cognitive function in the locked-in syndrome

OBJECTIVE

The lockedin syndrome (LIS) originates from a ventro-pontine lesion resulting in a complete quadraplegia and anarthria. Classically, communication remains possible by means of spared vertical eye movements and/or blinking. To allow assessing cognitive functions in LIS patients, we propose here a neuropsychological testing based on eye-coded communication.

METHODS

Ten chronic LIS survivors were assessed 1 to 6 years after their brain insult. One patient was evaluated subacutely (at 2 months) and retested at 6 and 16 months. Neuropsychological testing encompassed short- and long-term memory, attention, executive functioning, phonological and semantic processing and verbal intelligence.

RESULTS

None of the patients showed alterations in verbal intelligence. Impairments in one or several tests were found in five patients. In three of these patients, neuropsychological deficits could be related to additional cortical or thalamic structural brain lesions. In the other 2 patients, weakness or signs of fatigue only were observed in one or two cognitive tasks. Repeated measures in a subacute patient with pure brainstem lesion indicate the recovery of good levels of cognition 6 months after injury.

CONCLUSION

Results indicate that LIS patients can recover intact cognitive levels in cases of pure brainstem lesions, and that additional brain injuries are most likely responsible for associated cognitive deficits in the LIS. Furthermore, a systematic neuropsychological assessment in LIS patients would allow detecting their cognitive deficits,which will contribute to improve their quality of life and of communication with family and medical caretakers.

Exhuming the body: revisiting the role of the visible body in ethnographic research

Looking back is often painful. Although in the first instance I might approach a research project with enthusiasm and confidence, in retrospect the sins of omission can become very obvious. In reviewing five research projects employing qualitative ethnographic methods, I explored the underacknowledged role of the visible body in these projects. Although the task of retrospection is blessed with the accumulated wisdom of others, I emphasize the importance of ongoing self-scrutiny and critical analysis of methodological dogmas for researchers and their practices.

Identity related to living situation in six individuals with congenital quadriplegia

PURPOSE

This study was a preliminary examination of structural aspects of identity, particularly identity associated with living situation, in individuals who have quadriplegia due to cerebral palsy.

METHOD

A hierarchical classes algorithm (HICLAS) was used to construct idiographic 'identity structure' models for three individuals who are living in an inpatient hospital setting and for three individuals living in community-based group residences.

RESULTS

Indices derived from the models indicate that the identity 'myself as one who has a disability' was structurally superordinate (i.e., resided at a high hierarchical level) for all six participants, suggesting a high level of importance of this identity in participants' sense of self. The models also indicate that while identity associated with one's particular living situation was superordinate for persons living in the hospital, it was not for persons living in community residences.

CONCLUSIONS

While conclusions based on this small sample are necessarily limited, the data suggest that identity associated with living situation might differ in structural centrality, and presumably subjective importance, for persons living in inpatient versus community-based settings.

The relationships among serum lipid levels, adiposity, and depressive symptomatology in persons aging with spinal cord injury

BACKGROUND

Cardiovascular disease (CVD) appears to occur prematurely in persons with spinal cord injury (SCI). Stress may play a significant role in the development of CVD. Depression is the most common form of stress complicating the care of persons with SCI.

METHODS

In 188 persons with SCI, 46% with tetraplegia and 54% with paraplegia, the relationship between depression and the serum lipid profile was studied. Depression was measured by the Older Adult Health and Mood Questionnaire (OAHMQ) for persons with disability. Total cholesterol, high density lipoprotein (HDL) and low density lipoprotein (LDL) cholesterol and triglycerides were measured; body mass index (BMI) was computed and percent body fat was determined by dual-energy x-ray absorptiometry (DXA).

RESULTS

Depression and level of SCI were found to have significant interactive effects on serum lipid levels. Serum total and LDL cholesterol, as well as triglycerides, were all higher among persons with paraplegia who were depressed compared to those who were not depressed. This was not found in persons with tetraplegia. Inverse relationships were evident between serum triglycerides and HDL cholesterol levels. Persons with paraplegia who were depressed had significantly more adiposity than those not depressed. BMI correlated directly with serum triglycerides and indirectly with serum HDL cholesterol.

CONCLUSION

Depression appears to be a strong determinant of adverse lipid profiles in patients with paraplegia. association between depression and adiposity in these patients compounds the risk for cardiovascular disease.

Psychological or physiological: Why are tetraplegic patients content?

OBJECTIVE

To assess the effects of spinal cord injury (SCI) on perceived health-related quality of life (QOL).

BACKGROUND

SCI is physically disabling, socially handicapping, and romantically limiting. Nevertheless, little is known about post-SCI neurocognitive and psychosocial life. Better understanding of the cognitive and emotional worlds of SCI patients is essential to better address and meet their needs and expectations.

METHODS

Twenty subjects with high-cord (T6 and above) complete (American Spinal Injury Association [ASIA] A) SCI (High SCI) were compared with 10 subjects with low-cord (T7 and below) ASIA A SCI (Low SCI) and with 11 Able-Bodied control subjects. Satisfaction with Life and Short Form-36 instruments were used to assess physical and emotional aspects of QOL. Analyses of variance were used to assess potential differences across groups.

RESULTS

Overall, satisfaction with life was the same among the groups. Expectedly, High SCI and Low SCI subjects reported lower physical functioning than Able-Bodied subjects (p < 0.0001). But, oddly, there were no differences in perceived physical role, physical health, or social functioning. Furthermore, High SCI subjects reported better perceived mental health than Able-Bodied control subjects (p = 0.004) and a trend over Low SCI subjects (p = 0.06), better perceived emotional role in society (p = 0.02), and greater vitality (p = 0.01) than Low SCI subjects and Able-Bodied subjects.

CONCLUSIONS

Despite severe physical impairment and disability and frequent medical complications, subjects with complete spinal cord injury at high anatomic levels report better than average quality of life, being overall content. Reasons for these findings are unclear. Psychological adaptive reactions are likely, but the possible role of physiologic and neurocognitive changes needs further exploration.