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To determine the effectiveness of Pilates exercises on falls risk factors.Prospective cohort, pre-test post-test study. Participants were selected using convenience and snowballing sampling. Pilates classes were held twice weekly for six weeks (1-h sessions) with a supplementary home programme.A test of cognitive function, the Montreal Cognitive Assessment (MOCA), was employed to determine eligibility for inclusion. The following fall-predictor variable measures were employed: the 16 item Falls Efficacy Scale (FES), the short International Physical Activity Questionnaire (IPAQ), the Functional Reach Test (FRT), the Timed Up and Go (TUG), the GAITRite® system, Platform FOOTWORKpro. Multivariate analysis ANOVA with time as within subject factor was used to test for differences between pre and post-test scores adjusted for the factor Pilates.twenty-seven participants completed the study, mean age = 70.4 (SD = 4.5). After adjusting for the effect of the factor Pilates "previous experience or no previous experience of Pilates", statistically significant differences were identified in the following domains: The TUG (p 0.001), FRT (p 0.001), velocity, swing and stance time and the Mediolateral sway (p 0.05). A significant difference was found between pre and post-test for anteroposterior sway in those with experience of Pilates (p 0.05) and interaction between time and Pilates experience in Physical Activity (p 0.05).Findings suggest that functional mobility, mobility, spatiotemporal parameters of gait, postural balance and physical activity improved in healthy older adults after 6 weeks of Pilates with a supplementary home programme.

Residents in mental health residential facilities often experience impaired occupational and social engagement. Although many residents would prefer living in a home of their own, individualized su...

To investigate the effects of Pilates on falls risk, fear of falling, postural balance, functional mobility, spatiotemporal gait parameters, mobility and physical activity in older adults.Randomized Controlled Trial (RCT).Sixty-one older adults, mean age 70.08 (SD = 5.51) were randomly allocated into a Pilates group (PG, n = 29) or control group (CG, n = 32). Intervention comprised a 12-week Pilates program, with exercises performed twice a week and supplementary exercises at home. The Montreal Cognitive Assessment (MOCA), was used to screen cognition.Fear of falling, postural balance (force platform), gait velocity (electronic walkway).Functional mobility, mobility, physical activity, and spatiotemporal parameters of gait. Statistical analysis was carried out using Generalized Estimating Equations (GEE). Covariates were adjusted.Positive effects were found for time effects: Time Up and Go (TUG), anteroposterior (AP) and mediolateral (ML) directions of balance, cadence, (stance, step and double support time). The step and double support time showed significant differences between the two groups (p 0.05). Interaction between time and groups was found for FRT. Age was a significant factor in TUG, FRT, postural balance for AP under open eyes conditions. Health status was significant for ML in eyes open condition. Gait was significant for age, height and health status.Effects of 12 weeks of Pilates intervention on functional mobility, mobility, postural balance and spatiotemporal gait parameters were identified. Further trials of a longer duration are warranted to determine the effectiveness of Pilates on falls prevention.

Background: Patients who are in a coma, a vegetative state or a minimally conscious state present a clinical challenge for neurological assessment, which is a prerequisite for establishing a prognosis and planning management. Several scales have been developed to evaluate these patients. The Wessex Head Injury Matrix is a comprehensive tool but is currently available only in the French and English languages. The aim of this study was to translate and evaluate the reliability of the Italian version of the scale. Methods: The original scale was translated according to a standard protocol: three separate translations were made, and a selected version was back-translated to check for any errors in order to obtain the most accurate Italian translation. A final back translation of the agreed version was made as a further check. The final version was then administered blind to a consecutive series of patients with severe acquired brain injury by two examiners. Inter-rater and test-retest reliability were assessed using a weighted Cohen’s kappa (Kw). Concurrent validity of the WHIM was evaluated by ρ Spearman’s correlation coefficient using the Glasgow Coma Scale (GCS) and the Coma Recovery Scale Revised (CRS-R) as the available gold standard. Results: Twenty-four patients (12 males and 12 females; mean age 59.9 ± 20.1; mean duration from index event 17.7 ± 20.0 days) with stroke (n = 15), traumatic brain injury (n = 7) and anoxic encephalopathy (n = 2) were included. Inter-rater [Kw 0.80 (95% CI 0.75–0.84)] and test-retest reliability [Kw 0.77 (95% CI 0.72–0.81)] showed good values. WHIM total scores correlated significantly with total scores on the GCS (ρ = 0.776; p < 0.001) and the CRS-R (ρ = 0.881; p < 0.001) demonstrating concurrent validity; Conclusion: The Italian version of the scale is now available for clinical practice and research.

Despite high demand, mental health services in primary care in Ireland are underdeveloped. People with mild/moderate anxiety, depression and unspecified psychological distress are frequently seen in primary care settings, mostly by general practitioners (GPs). Occupational therapists have the potential to contribute to service-provision with interventions specially designed for the targeted group e.g. the Redesigning Daily Occupations programme (ReDO-10).This study aimed to explore the feasibility of a future RCT of the ReDO-10 programme in Ireland and the contextual factors that would influence future implementation.Using a multi-phase, mixed-method design, qualitative and quantitative data were gathered from key stakeholders: ReDO-10 participants (ReDO-10 was acceptable to participants who reported improvements in their occupational patterns and valued the group-based format. GPs and occupational therapists welcomed the intervention, but acknowledged the limitations of time and resources in the Irish primary care context.ReDO-10 is feasible to explore in a future RCT in Ireland and this study provides important context for future implementation and/or research.

This article describes an innovative transnational education project involving three European universities, funded through ERASMUS+. One of its aims was to develop and provide a curriculum to facilitate students’ understanding and identification of occupational (in)justice by exposing them to marginalised people living in three European communities with differing cultural, social, and political systems. Occupational injustice is an ongoing deprivation or patterns of disruption that creates health burdens, barriers to educational and social opportunities, and risk to the individual’s lifespan. We describe how a transnational educational collaboration offered a new way of facilitating learning of occupational (in)justice in a practical way to stimulate the application of concepts to discipline specific thinking and engage students in debate about new areas of potential practice which are transformational. The educational theory underpinning the project is discussed, together with a description of how authentic learning experiences supported the development of occupational justice knowledge and justice-focused practice. The team are grateful to all the community partners who supported the project, offered new sights, and readily engaged with the students throughout the 3 years. The team are thankful for co-funding by the ERASMUS+ programme of the European Union (Grant no. 2016-1-SE01-KA203-022102) to support the development and delivery of this project. peer-reviewed 2022-02-09

Anxiety and stress-related disorders are highly prevalent and impede participation in life activities. Occupational therapists work extensively with people diagnosed with these disorders but the effectiveness of their interventions is unclear. A systematic search strategy identified 19 papers describing 13 studies. Studies varied in methodology, intervention type, and theory base. The results show the potential for lifestyle approaches, occupational science-based programs, and skill-building to improve mental health. The variety of interventions and methodologies of many studies means that the effectiveness of occupational therapy interventions for this population is not yet determined. High-quality research is required to replicate interventions with emerging potential for effectiveness. peer-reviewed 2020-01-15

Residents of mental health facilities may be at risk of occupational injustices if their participation is restricted. A case study approach was adopted to explore the experience of engaging in mean...

This article examines scoring procedures for Goal Attainment Scaling (GAS) and suggests a new scoring procedure to communicate GAS outcomes in longitudinal studies. Analysis is based on longitudina...

Brain injury survivors are considered to be at high risk for infections. The infection and resultant cognitive deterioration is well established for people with dementia; however, to date, no investigation has been conducted for patients in prolonged disorders of consciousness (PDOC). This study sets out to examine whether the results of regular Wessex Head Injury Matrix (WHIM) assessments provide an indicator that might identify early signs of infections in PDOC patients. Both retrospective and prospective approaches were used. The retrospective study examined the WHIM scores of 21 patients and the prospective study examined the WHIM scores of 22 PDOC patients. The results indicated that WHIM total score decreased due to the infections in 17 of the 21 infection cases (p

As the prevalence and incidence of disorders of consciousness (DoC) increase, researchers and clinicians are tasked with developing best practice assessment techniques. Neurobehavioural assessment remains the most clinically available method of measuring consciousness. Neuroimaging and other physiological measurements are demonstrating promise in supporting this assessment but many of these techniques require further research and are not widely available in sub-acute and long-term care settings. No study to date has explored in-depth complementary use of multiple neurobehavioural assessments in aiding beside assessment of consciousness. This paper describes and proposes complementary use of two commonly used standardised neurobehavioural assessments. The Sensory Modality Assessment and Rehabilitation Technique (SMART) and the Wessex Head Injury Matrix (WHIM) both have specific aims and play an important role in behavioural assessment across the care continuum. This paper proposes that when used together appropriately these two assessments promote best practice and strengthen behavioural assessment of consciousness by providing increased opportunities to capture awareness. Further research into use of more than one neurobehavioural tool is highlighted as an important area of inquiry for this heterogeneous population not only in clinical practice but also in research.

Background Anxiety and stress are prevalent in general practice and primary care settings, particularly among women. The ‘Redesigning Daily Occupations’ (ReDO) programme is a manualised occupational therapy-led intervention designed to improve balance in daily life and reduce stress. A pilot study aiming to explore the feasibility of implementing ReDO in primary care settings was carried out. Despite predicted demand, recruitment was slower than anticipated. Objectives To understand the feasibility and acceptability of ReDO from the perspective of stakeholders. To understand the study processes better. To use this information in decision–making to plan future intervention evaluation/development. Methods Six women diagnosed with anxiety or stress-related conditions were recruited to take part in the 10 week group programme via their general practitioner. Qualitative interviews were completed with five group participants, two group facilitators, and nine general practitioners (n=17). The data analysis was informed by principles of qualitative evaluation research where the focus is on achieving practical, actionable understandings of real-world issues in context.1 Results Results demonstrated conflicting perspectives on the feasibility of ReDO. The participants noted changes in their daily lives in mental health and daily functioning and recommended longer interventions. In contrast, the length of the intervention was balanced with a heavy clinical workload for the occupational therapists, while general practitioners felt the length of the programme restricted study recruitment. The occupational therapy programme facilitators and participants contributed to understanding how changes had taken place within the context of group dynamics adding to insight into who the intervention might best be suited to. Conclusions The qualitative approach contributed greatly to decision-making. The programme will be delivered again in 2019 with small changes to the inclusion/exclusion criteria and recruitment strategy. Future research will explore the mechanism of change as understood by participants and facilitators within this intervention. Reference Patton M. Qualitative research and evaluation methods: Integrating theory and practice (4th Edition), 2015. Thousand Oaks, CA: SAGE Publications, Inc.

To examine the extent to which personal factors (age, socioeconomic grouping, and preterm birth) and adaptive behaviour explain the participation patterns of young children.65 Children 2-5 years old with and without a history of preterm birth and no physical or intellectual disability were selected by convenience sampling from Galway University Hospital, Ireland. Interviews with parents were conducted using the Adaptive Behaviour Assessment System, Second Edition (ABAS-II) and the Assessment of Preschool Children's Participation (APCP). Linear regression models were used to identify associations between the ABAS-II scores, personal factors, and APCP scores for intensity and diversity of participation.Adaptive behaviour explained 21% of variance in intensity of play, 18% in intensity of Skill Development, 7% in intensity of Active Physical Recreation, and 6% in intensity of Social Activities controlling for age, preterm birth, and socioeconomic grouping. Age explained between 1% and 11% of variance in intensity of participation scores. Adapted behaviour (13%), Age (17%), and socioeconomic grouping (5%) explained a significant percentage of variance in diversity of participation controlling for the other variables.Adaptive behaviour had a unique contribution to children's intensity and diversity of participation, suggesting its importance.

[No abstract available] peer-reviewed

Modafinil is best known as a sleep regulator among healthy individuals, but studies suggest that it reduces excessive daytime sleepiness in patients with brain injury. This retrospective pilot study evaluated the effectiveness of Modafinil for people with a prolonged disorder of consciousness and whether those with a traumatic brain injury did better than those with a non-traumatic brain injury.Twenty four prolonged disorder of consciousness patients who were prescribed Modafinil, were assessed at least four times both before and during treatment. The Coma Recovery Scale-Revised was used to determine if patients had a disorder of consciousness and the Wessex Head Injury Matrix was used to monitor behavior during baseline and treatment periods. Patients with a traumatic brain injury (N = 12) were compared with those with non-traumatic brain injury (N = 12). A chi-square test with significance at 0.05 was used and when frequencies were below 5 a Fisher's Exact Test was used.Cognitive improvements were noted in domains of wakefulness, awareness, concentration, tracking and following commands. Significant differences were found for the whole group between baseline and Modafinil (xModafinil appears to be beneficial for enhancing cognition in prolonged disorder of consciousness patients. Traumatic brain injury patients benefited more than non-traumatic brain injury patients. Implications for Rehabilitation People with prolonged disorders of consciousness are those in coma, a vegetative state or a minimally conscious state. Sensorimotor and neuromodulations (pharmacological and brain stimulation) are the available treatment strategies to this group. Modafinil promotes attention, concentration and maintains wakefulness in a patient with narcolepsy, obstructive sleep apnea and shift work sleep disorders. In a relatively small sample, this retrospective pilot study shows the effectiveness of Modafinil in conjunction with good care, suitable medications and multidisciplinary rehabilitation in enhancing arousal in prolonged disorders of consciousness patients.

In two experiments involving word-stem completion, an advantage was found for errorless over errorful-learning conditions, for both severely and moderately memory-impaired participants. This advantage did not depend on the implicit/explicit nature of the question asked. Additional tests showed that subsequent recognition of target items was good for both groups, but only in the absence of lures derived from participants' prior errors. Source-memory was shown to be virtually absent in the severely impaired group and only weakly present in the moderately impaired group. This combination of results suggests that preserved implicit memory, in the absence of explicit memory, is sufficient for an errorless-learning advantage to accrue.

Diagnosis of the vegetative state (VS) or minimally conscious state (MCS) is dependent on the presence or absence of behavioural variables. Diagnosis of the VS in the case of those who have had a severe head injury does not occur for several months after injury. If such outcomes could be predicted it would facilitate appropriate and timely referrals to specialist rehabilitation units. This paper describes a follow up study of patients observed prospectively after severe head injury and followed up four years later. Thirty patients had made a moderate or good recovery and eight met criteria for MCS. Analysis of early observations together with outcome data suggest that the duration of time taken to achieve some early behaviours may be predictive of poorer outcome.

This was an exploratory study, with the purpose of developing and piloting an intervention for people with mild cognitive impairment (MCI) and their family members using cognitive rehabilitation. A case series design was used with pre- and post-intervention and 3-month follow-up outcome measures. Five participants (two males, three females; mean age 75 years) with a diagnosis of MCI attended the memory clinic with a family member. Intervention consisted of six to eight individual sessions of cognitive rehabilitation consisting of personalized interventions to address individually relevant goals delivered weekly. The main rehabilitation strategies utilized were external aids, personal diary, face-name association, relaxation, and encouraging participants to develop habits and routines. The primary outcome measure was goal attainment as assessed by Goal Attainment Scaling. Secondary outcome measures included measures of memory, anxiety, depression, and activities of daily living. Qualitative data were collected post-intervention by interview. Post-intervention 84% of the goals were attained, with 68% maintained at a 3-month follow-up. Mean anxiety and depression scores decreased during the intervention. No significant changes were recorded on a test of memory. The findings suggest that the strongest effect was in relation to compensatory strategies for prospective and episodic memory deficits. Feedback from participants during qualitative interviews indicated that they found strategies useful and implemented them in their daily routines. The findings support the use of a dyadic cognitive rehabilitation intervention for people with MCI and memory difficulties.

Outcome studies of premature babies have focused their assessments predominately on neurodevelopmental impairments without relating these deficits to the impact they have on a child’s everyday life. This study aims to determine whether very ‘preterm birth alone’ impacts on a child’s ability to participate in and carry out childhood activities. Forty-four former premature infants between 6 months and 5 years 6 months, born in Galway University Hospital, Ireland, without physical or intellectual disability, were compared with 51 age-matched term-born infants. Study infants had an average gestation of 29 weeks and birth weight of 1,145 g. Functional skills were assessed using the Adaptive Behavior Assessment Scale-II and the Assessment of Preschool Children’s Participation. Premature infants had significantly lower mean scores in overall adaptive behaviour compared to term infants, regardless of whether chronological (difference = 13.6, 95 % (CI) = [8.2, 19.1]) or corrected (difference = 6.6, 95 % CI = [1.4, 11.8]) age was used. Premature infants had lower mean scores in conceptual, social and practical skills, but no difference was found between the groups in intensity or diversity of participation. Conclusion: Premature infants had significantly lower scores in adaptive behaviour than term infants. This measurable effect of preterm birth on ‘childhood occupations’ merits further investigation.

We report on the development of a new assessment tool to monitor recovery after severe traumatic brain injury (TBI). Although a number of scales exist to identify such recovery, most are limited if one is interested in monitoring small changes or in setting goals for rehabilitation. This is due to the fact that items are too broad, they may cross more than one dimension (e.g. cognition and motor functioning) and there is a danger that recording of responses may be too subjective. The Wessex Head Injury Matrix (WHIM) was developed to avoid these problems. We observed 88 people with severe TBI. These were consecutive admissions to two hospitals. Mean coma duration was 14 days and mean duration of post traumatic amnesia (PTA) was 56 days. Of 145 behaviours observed, we selected 62 and each behaviour was compared to every other behaviour to determine a likely order of recovery. The resulting WHIM is an observational tool to assess and monitor cognitive recovery after severe head injury. It can be used with patients who are in coma, just out of coma or who are minimally conscious. Two case examples are provided.

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.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.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.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.

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.

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.

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-Liege 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...

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 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.

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...

Initial observations that patients in coma showed a variety of responses when a cloth was placed over their faces generated a study investigating whether these patients could learn to remove the cloth. A method of backward chaining was used to teach the patients. Three experiments are reported. In the first study, five patients learned to remove the cloth while still in coma. In the second study, patients with a much lower Glasgow Coma Scale (GCS) score underwent the same procedure and all three removed the cloth while still in coma. The third experiment aimed to develop this procedure and two patients were trained to carry out other tasks using the same backward chaining technique. Both carried out the tasks while still in coma. The results of the study demonstrate that patients in coma following traumatic head injury developed increasingly reliable responses to specific stimuli. The theoretical and practical implications of these results are discussed.

The monitoring of behavioural events during and after coma is important in determining the nature and pace of recovery, in detecting early signs of deterioration, in the evaluation of coma stimulation and other rehabilitation programmes, and in identifying the persistent vegetative state. There are a number of difficulties in constructing objective, reliable, valid measures of significant behavioural events which are also easy to administer by the bedside. This paper reviews the many behavioural scales which have been developed in the search for quantifiable data on recovery, and presents some pilot data on a new scale of visual awareness.

As the population of elderly people rises, so too does the incidence of stroke. Cognitive impairment is considered to be a strong predictor of outcome following stroke, and elderly patients may have pre-existing, undiagnosed cognitive impairment as well as impairment caused by the stroke. The present study describes the performance of patients with unilateral hemispheric stroke (right hemisphere, n = 38; left hemisphere, n = 17) on the Middlesex Elderly Assessment of Mental Status (MEAMS), which was developed as a screening tool of cognitive dysfunction for elderly patients.1 Patients had no documented evidence of premorbid cognitive impairment. All patients with scores at borderline or below (n = 7) had language impairment and thus had difficulty with the language-oriented tests. Differences between right and left hemisphere groups are also presented and their performance on the various subtests discussed. It is concluded that the MEAMS is a useful instrument in screening stroke patients for cognitive impairment.

This study compared memory and attention functioning in three groups of patients: those in post-traumatic amnesia (PTA), those with the amnesic syndrome (AS) and those with chronic memory impairment (CMI) following severe head injury, but who were no longer in PTA. We also tested a control group, most of whom had sustained orthopaedic injuries. Subjects were assessed on tests of immediate and delayed memory, semantic and episodic memory, procedural learning, speed of comprehension, and attention. Patients in PTA differed from all other groups on semantic processing (errors), verbal fluency (animals) and simple reaction time. The best measures for discriminating PTA were accuracy of comprehension, verbal fluency, delayed logical memory, simple reaction time, and backward digit span.

Introduction the influence of hormones in various psychological aspects of attention deficits are being studied increasingly more often and their significance has been acknowledge. However, hormonal fluctuations and the influence of estrogen on the brain has not been considered or treated. Recent studies show the influence of estrogen in the functioning and the functional consequences, observing an improvement in functioning, particularly in attention, of women during phases with high levels of estrogen. This can influence the treatment of Deficit Attention/Hyperactivity (ADHD) in females. Methodology a systematic review was performed, searching for studies on the following databases: MEDLINE (PubMed), The Cochrane Library and EMBASE. The search was made using the Medical Subject Headings (MeSH) terms 'Sex/gender”, 'Response treatment” and 'ADHD/Attention-Deficit/Hyperactivity Disorder. Limiters were applied and Boolean logic used to expand and restrict searches. A total of 208 articles were identified, and 6 were included. Results three main findings were identified: treatment with stimulant drugs is effective independent of gender; women had more complex presentation of ADHD, with more comorbidities such as depression and anxiety and women had one statistically significant gender-by-treatment response, but only on emotional dysregulation. Conclusions it is as yet uncertain as to the role of gender in the treatment of ADHD. While some evidence is more persuasive than others, results still can not be used safely by the medical community. Therefore further more study needs to be carried out to clarify the answer to this question.

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 …

(2004). Difficulties in diagnosing the vegetative state. British Journal of Neurosurgery: Vol. 18, No. 1, pp. 5-7.

The rational management of patients recovering from posttraumatic coma has been plagued by a paucity of hard data addressing the role of different physical interventions. In this paper, Oh and Seo present some useful and thorough research in a clinical area that is critically under-researched. As technology, knowledge and understanding advances, the number of patients surviving severe brain injury is increasing. Although the majority make a good recovery, a minority remain in coma, the minimally conscious state or the vegetative state. It has been estimated that as many as six to eight in 100 000 people each year sustain a moderate or severe head injury, with long-term consequences. Unfortunately, this is not reflected in the provision of health care or research effort in this field. These patients are often ignored by modern health care. While billions of research pounds and dollars have been spent on the investigation of (mainly ineffective) acute neuroprotective interventions, little research effort has been directed at dealing with the clinical reality of patients who are left severely disabled following brain injury. There should no longer be any doubt that early rehabilitation is essential to the effective care and long-term recovery of patients who have sustained a brain injury. As a result, the interface of clinical responsibility between acute care and rehabilitation has become increasingly blurred, with acute care teams taking greater responsibility for early rehabilitation (Von Wild, 2001). It is no longer appropriate to initiate rehabilitation only after acute care has come to an end, not only for self-evident logistic and clinical reasons, but also because the biology of acute inflammation following brain injury imperceptibly merges into processes involved in repair Correspondence: Leslie Gelling, Research Officer, School of Community Health and Social Studies, Anglia Polytechnic University, East Road, Cambridge, CB1 1PT, UK, E-mail: leslie.gelling@ntlworld.com

Background Although much literature has focused on the cognitive, motor and behavioural sequelae of preterm birth, little attention in the medical literature has addressed its impact on everyday life skills. Few standardised assessments that measure adaptive behaviour are normed on a UK/Irish population of children. The Adaptive behaviour Assessment Scale-II (ABAS- II) is a well standardised standalone assessment that has also been adopted as part of the Bayley III assessment to measure the adaptive behaviour of young children, including preterm infants. The ABAS-II is normed, however on a North American population. Aim To ascertain whether the North American normed ABAS-II is a valid measure of adaptive behaviour for Irish VLBW preschoolers. Methodology Parents of 51 full term infants (6 months–5 years 6 months of age) born in GUH were assessed using the Parent Questionnaire of the ABAS-II. Results were compared to North American normative data. Results No difference was found between the ABAS-II General Adaptive Composite of the Irish controls and North American normative data. Of the three domain scores, there was a significant difference in scores in the Social domain, in favour of the Irish controls (p = 0.01), and the practical domain in favour of the North American sample (p = 0.49). No difference was found between the groups in the Conceptual Domain. Conclusion Caution is required in interpreting the results of Irish VLBW infants when using adaptive measures standardised on a North American population. The results suggest a measurable difference in cultural influences on Adaptive Behaviour that warrant further investigation.

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.

A substantial number of brain injured patients complain of memory deficits, despite achieving scores within the normal range on tests of memory functioning. The Rivermead Behavioural Memory Test is an ecologically valid test used to assess everyday memory problems. This test is effective at detecting moderate to-severe impairments, yet subtle memory deficits may go undetected for some patients who achieve a score within the normal range. The initial development of an extended version of this test (RBMT-E), designed to detect subtle decrements in memory performance, has recently been described. The performance of 16 brain injured patients was assessed on both the RBMT and the KBMT-E. The performance of these patients on the RBMT-E was compared with that of matched controls. Overall, the patients performed significantly worse than the controls, and showed particular difficulty in two subtests involving recalling a route and remembering to deliver a message. Those patients who scored in the 'normal' range on the RBMT could be further differentiated on the basis of their RBMT-E scores into 'good', 'average' and 'poor' performance categories. The patients' performance was not significantly associated with general intellectual ability. These results suggest that the RBMT-E may be a useful clinical tool to aid therapists in the assessment of subtle impairments of everyday memory performance following brain injury.

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.

'Reality orientation training' (ROT) is a well-established therapy used with the elderly, especially those with dementia. It aims to improve orientation and reduce negative behaviours, e.g. confusion. ROT has been recommended for non-demented patients with acquired neurological impairment. However, this suggestion has not been investigated further in controlled trials. This paper describes an informal 24 h ROT programme with an amnesic subject (H.J.). It combined single-case experimental designs derived from behaviour therapy. Target behaviours were items of temporal orientation--current time/time of day, year, season, month and day of week. Orientation regarding the current date was not trained, and thus served as control variable for non-specific effects (e.g. spontaneous recovery). In order to improve oriented behaviour in different relevant situations outside the clinic, we chose 24 h ROT instead of formal therapeutic sessions. The patients' spouse offered 24 h ROT at home 7 days a week. This consisted of reminding the patient of orientation information, e.g. the current day of the week in different situations. Furthermore, negative behaviours such as irrelevant questions were ignored. The patients' spouse was trained and supervised to carry out this task in 27 sessions each lasting 10 min. For 14 weeks supervision was provided twice a week in the clinic (i.e. 2 x 10 min). Afterwards the spouse continued to apply ROT at home without further supervision in two follow-up periods. As expected, learning was slow but reliable. Generalization of improvement to another setting was shown (home vs clinic). Stable therapeutic gains over a long follow-up period could be demonstrated.(ABSTRACT TRUNCATED AT 250 WORDS)