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Objective: To compare the appropriateness and responsiveness of the Barthel Index and the Functional Independence Measure (FIM) during early inpatient rehabilitation after single incident brain injury. Design: Cohort study. Setting: A regional neurological rehabilitation unit. Patients: Two hundred and fifty-nine consecutive patients undergoing inpatient comprehensive neurological rehabilitation following a vascular brain injury due to single cerebral infarction (n=75), spontaneous intracerebral haemorrhage (n=34) and subarachnoid haemorrhage (n=43), and 107 patients who had sustained traumatic brain injury. Measurements: Admission and discharge FIM total, physical and cognitive scores and the Barthel Index were recorded. Appropriateness and responsiveness in the study samples were determined by examining score distributions and floor and ceiling effects, and by an effect size calculation respectively. Non-parametric statistical analysis was used to calculate the significance of the change in scores. Results: In all patient groups there was a significant improvement (Wilcoxon's rank sum, P < 0.0001) in the Barthel Index (mean change score: vascular 3.9, traumatic 3.95) and FIM (mean change score: vascular 17.3, traumatic 17.4) scores during rehabilitation, and similar effect sizes were found for the Barthel Index (effect size: vascular 0.65, traumatic 0.55) and FIM total (effect size: vascular 0.59, traumatic 0.48) and physical scores in all patient groups. In each patient group the cognitive component of the FIM had the smallest effect size (0.35-0.43). Conclusions: All measures were appropriate for younger (less than 65 years of age) patients undergoing early inpatient rehabilitation after single incident vascular or traumatic brain injury. The Barthel Index and the total and physical FIM scores showed similar responsiveness, whilst the cognitive FIM score was least responsive. These findings suggest that none of the FIM scores have any advantage over the Barthel Index in evaluating change in these circumstances.

Background: The outcome of rehabilitation interventions following brain injury is commonly rated by disability scales. Goal-setting and achievement are important in inpatient rehabilitation, but seldom assessed as outcomes. Objective: To compare the information acquired from using disability ratings and goal attainment/variances as outcome measures in brain injury rehabilitation. Setting: An inpatient regional neurological rehabilitation unit. Subjects: One hundred and seventy-seven patients admitted after single incident brain injury over a three-year period. Main measures: (1) Disability outcomes by the Barthel Index and the Functional Independence Measure, (2) goal achievement and variance distribution, and (3) the influence of diagnosis and demographics on these measures. Results: Patients improved significantly on all disability scales employed (p < 0.0001), with the baseline admission scores being inversely correlated with changes in dependency by discharge (rho∼0.4). The median attainment rate of long-term goals was 75% per patient. Nonachievement was most frequently due to cognitive problems (38%), followed by behavioural difficulties and physical limitations (18% each). Goal achievement correlated poorly with disability outcome at discharge (rho∼0.3). Patients who accomplished all their goals tended to be less disabled at admission. Diagnostic groups and demographic factors had little influence on either disability or goal achievement outcomes. Conclusions: The use of a simple goal achievement and variance coding scheme has been relatively straight forward to incorporate into the daily practice of the unit. It provides useful information on rehabilitation process and outcome after brain injury that is complementary to the utilization of disability measures.

To describe aspects of process and outcome during early inpatient rehabilitation of younger adults after single incident brain injury.Analysis of a database of 290 patients discharged from an inner-city hospital based inpatient unit for younger adults after single incident neurological events, over a 5-year period.Analysis showed a stable case-mix of patients over the 5 years surveyed with a preponderance of young male patients after traumatic brain injury. Improvements in patients' disability and dependency, measured by the Barthel Index and Functional Independence Measure, were recorded in the majority of patients. The ethnic diversity of the patients, reflecting the multi-cultural nature of the catchment population, did not appear to affect rehabilitation outcome. Failure to record improvement in 15% of patients was related to the floor and ceiling effects of the instruments. A useful regression equation was produced relating length of stay to Barthel score on admission.These data demonstrate the changes that occur during early inpatient rehabilitation after single incident brain injury. They explore clinical indicators of dependency and outcome, and aspects of resource utilization that characterize our service. Publication of data of this sort, from this and other units, should encourage the development and improvement of current rehabilitation service delivery after brain injury.

The authors show that prismatic adaptation can reduce tactile inattention in stroke patients with unilateral neglect. Four patients with visuospatial neglect and tactile extinction underwent 10-minute application of 20degrees right-shifting prismatic lenses during pointing. This improved contralesional tactile perception in all patients, even for a task requiring no exploration or spatial motor responses. This finding suggests a potential role for prismatic adaptation in the rehabilitation of multiple sensory modalities in patients with neglect

A patient with a severe dyscalculia and a mild arabic number dyslexia is described. He could perform simple addition and subtraction sums with oral presentation. However with written arabic number sums he was impaired with addition but not with subtraction. These findings require modifications to current models of arithmetic processing which have suggested that numerical inputs are converted into abstract internal representations before arithmetical processing can occur.

In this paper we describe a patient with a severe global dysphasia who provides an example of a category specific access impairment. Using matching to sample techniques it was possible to demonstrate the selective preservation of her ability to comprehend proper nouns coupled with impaired comprehension of common nouns. It was found that for the object names category M.E.D. performed better on the first presentation of an item than she did on subsequent presentations. Her performance was also found to be affected by presentation rate and an analysis of her responses showed marked inconsistency when the same stimuli were administered more than once. This category specific access impairment suggests the relative independence of the cognitive mechanisms responsible for the access of different semantic categories.

Some of the most striking symptoms after prefrontal damage are reduction of behavioral initiation and inability to suppress automatic behaviors. However, the relation between these 2 symptoms and the location of the lesions that cause them are not well understood. This study investigates the cerebral correlates of initiation and suppression abilities assessed by the Hayling Sentence Completion Test, using the human lesion approach. Forty-five patients with focal brain lesions and 110 healthy matched controls were examined. We combined a classical group approach with 2 voxel-based lesion methods. The results show several critical prefrontal regions to Hayling Test performance, associated with either common or differential impairment in ‘‘initiation’’ and ‘‘suppression’’ conditions. A crucial role for medial rostral prefrontal cortex (BA 10) in the initiation condition was shown by both group and lesion-mapping methods. A posterior inferolateral lesion provoked both initiation and suppression slowness, although to different degrees. An orbitoventral region was associated with errors in the suppression condition. These findings are important for clinical practice since they indicate that the brain regions required to perform a widely used and sensitive neuropsychological test but also shed light on the regions crucial for distinct components of adaptative behaviors, in particular, rostral prefrontal cortex.

A single case study of an attentional dyslexic is reported. The patient B.A.L. was able to read single letters and single words presented in isolation without difficulty. However, his reading of prose was very disrupted and his ability to read rows of letters and words was significantly impaired. A “flanking” procedure, in which there was a single target item, flanked by other stimuli, was used in a series of experiments to analyse his dyslexic impairment. First it was established that his attentional deficit was specific to reading in so far as the patient did not have comparable difficulties with pictorial material. His performance in the flanking experiments was consistently impaired; and furthermore was unaffected by speed of presentation, the number of flanking stimuli, and the spatial arrangement of the flanking stimuli. The important exception was when the flanking stimuli were of a different category. There was no decrement in performance when target letters were flanked by words or when words were flanked by letters. This study both corroborates and extends the original account of attentional dyslexia (S hallice and W arrington , Neuropsychologia15, 31–41, 1977) in terms of a damaged “filter” mechanism controlling the transition from a parallel to a serial stage of reading processing. The categorical effects reported here indicate that such a filter must be post lexical and suggest further that there are multiple filters in the reading system.

A follow-up study of a patient, WJ, with a very severe prosopagnosia is reported. After a stroke he became a farmer and acquired a flock of sheep. He learnt to recognize and name many of his sheep, and his performance on tests of recognition memory and paired-associate learning for sheep was significantly better than on comparable tests using human face stimuli. It is concluded that in some instances prosopagnosia can be a face-specific disorder.

Atthisearlystageinthe21stcentury,clinicalneuropsychologyisrightlyfindingitsfeetasawell-delineatedandexpandingclinicalspecialtywithinClinicalPsychology.It has moved away from the purely diagnostic role it acquired after the SecondWorldWar,tooneinwhichthecharacterizationofaperson’sfunctionalstrengthsand weaknesses and the explanation of their behaviour have become central inextendingtherangeofmeaningfulquestionsthatcanbeposedaboutanindividualpatient’s presentation. Clinical neuropsychology is now very much valued as notsimply involving the assessment of cognitive abilities in patients with cerebralpathology,butalsoasplayingamajorroleintherehabilitationofsuchpeople.Itisalsocontributingtotheunderstandingoftheimpactoncognitivefunctioningofdisorders hitherto conceptualized as psychiatric or ‘functional’ (rather than‘organic’)—forexample,depressionorschizophrenia—andisbeingusedtounder-stand and hence possibly conceptualize in neuropsychological terms a variety ofantisocial or maladaptive behaviours. Neuropsychology has expanded its area ofenquirybeyondthetestingroomandintotheimplicationsofcognitiveimpairmentforeverydaylife,witharangeofteststhatarestrivingtobemoreecologicallyvalid(e.g.,Wilsonetal.,1996)aswellasenvironmentallybased(ShalliceBAldermanetal.,2003).It is therefore important that all clinical psychologists, and not just thoseworkinginspecialistneuropsychologicalsettings,haveabasicgroundinginneuro-psychology.Perhapsthesimplestwayofillustratingthewidespreadapplicationofneuropsychologicalskillscomesfromthetypesofquestionsthatclinicalpsychol-ogists might need to answer about their patients. Thus a clinical psychologistworking in a primary care setting, being the first person to undertake a formalassessmentofapatient,mightneedtodeterminewhethertheirpatient’scomplaintofpoormemoryrepresentsaconditionthatmeritsreferralforfurtherinvestigation

List of Contributors ix Preface xv Preface to the First Edition xix Part 1 General Introduction 1 General Introduction:What Is the Relevance of Neuropsychology for Clinical Psychology Practice? 3 Laura H. Goldstein and Jane E. McNeil Part 2 Neuroscience Background 2 Neuroanatomy and Neuropathology 23 Nigel J. Cairns 3 Neurological Investigations 61 John D. C. Mellers and Naomi A. Sibtain Part 3 Neuropsychological Assessment: General Issues 4 Psychological and Psychiatric Aspects of Brain Disorder: Nature, Assessment and Implications for Clinical Neuropsychology 87 Richard G. Brown 5 The Effects of Prescribed and Recreational Drug Use on Cognitive Functioning 105 Jane Powell 6 Quantitative Aspects of Neuropsychological Assessment 129 John R. Crawford Part 4 Adult Neuropsychology 7 Disorders of Memory 159 Jonathan J. Evans 8 Disorders of Language and Communication 185 Pat McKenna and Karen Bonham 9 Executive Dysfunction 209 Paul W. Burgess and Nick Alderman 10 Acquired Disorders of Voluntary Movement 239 Laura H. Goldstein 11 Visuo-Spatial and Attentional Disorders 261 Tom Manly, Jessica Fish and Jason B. Mattingley 12 Disorders of Number Processing and Calculation 293 Jane E. McNeil Part 5 Neuropsychology: Specialist Areas ofWork 13 Clinical Neuropsychological Assessment of Children 317 Jody Warner-Rogers 14 Neuropsychological Assessment of Older Adults 347 Robin G. Morris and Rebecca L. Brookes 15 Neuropsychology of Frontotemporal Lobar Degeneration: Frontotemporal Dementia, Semantic Dementia and Progressive Non-Fluent Aphasia 375 Julie Snowden 16 Very Severe and Profound Brain Injury 397 J. Graham Beaumont 17 Neuropsychology and the Law 415 Graham E. Powell 18 Mental Capacity 445 Camilla Herbert Part 6 Rehabilitation 19 Theoretical Approaches to Cognitive Rehabilitation 463 Fergus Gracey and Barbara A. Wilson 20 Planning, Delivering and Evaluating Services 483 Camilla Herbert 21 Research Design and Outcome Evaluation 505 Andrew Worthington 22 Interventions for Psychological Problems After Brain Injury 527 Andy Tyerman and Nigel S. King 23 Neurorehabilitation Strategies for People with Neurodegenerative Conditions 549 Jennifer Rusted and Esme Moniz-Cook 24 Driving in Neurological Patients 567 Nadina B. Lincoln and Kate A. Radford Index 589

The theoretical distinction between arithmetic facts and procedures was first made by Groen and Parkman (1972). This was confirmed with a neuropsychological single case described by Warrington (1982) who had impaired arithmetical facts but well preserved arithmetical procedures. Since this time there have been several patients described who showed a selective impairment of arithmetic facts. There have also been reports of cases with impaired arithmetical procedures. However, there has not yet been a case reported with the selective impairment of procedures in the context of intact arithmetic facts. This paper describes a patient, SR, with probable Alzheimer's dementia who had well preserved addition, multiplication and subtraction facts but who nevertheless had severe difficulties with a range of arithmetical procedures such as multidigit sums, decimals and fractions. The implications of this case for current theoretical models are discussed.

Following a 5 cm left frontal lobectomy for the removal of a mixed astrocytoma-oligodendroglioma, a 51 year old right handed man showed a marked dissociation between his performance on standard neuropsychological tests and his everyday behaviour. In contrast to his intact neuropsychological test performance, he was impaired on a test of "strategy application" which requires goal articulation, plan specification, self-monitoring, and evaluation of outcomes, as well as the establishment of mental "markers" to trigger specific behaviour. Strategy application disorder can therefore be produced by a unilateral circumscribed frontal lobe lesions.

This report describes a person who confabulated following an anterior communicating artery aneurysm. His confabulation was limited to one very circumscribed area of his life and remained stable for twelve weeks, eventually improving with rehabilitation. It is argued that a content-specific confabulation of this nature challenges current theories of confabulation, and an integrative explanation is given based on previous findings by Burgess and Shallice (1996b) of the mechanisms of autobiographical recollection in healthy people.

Theoretical accounts of post-traumatic stress disorder (PTSD) suggest that memory for a precipitating event is crucial for its development. Indeed, Sbordone and Liter (1995) have recently argued that mild traumatic brain injury and PTSD are mutually exclusive disorders. A case is described who sustained a severe head injury in a road traffic accident. He had a retrograde amnesia of two days and a post-traumatic amnesia of four weeks. Six months after his accident he was found to be suffering from a number of anxiety symptoms, including nightmares and intrusive thoughts, consistent with a diagnosis of PTSD. The implications of this case for theories of PTSD are discussed.

In this study we describe an investigation into the residual written word retrieval skills of M.E.D., a patient with a severe aphasia. M.E.D.'s performance on written naming and writing to dictation tasks showed a distinctive pattern of performance across semantic categories. The patient's ability to write the names of countries and famous people was consistently superior to her ability to write the names of objects. These results could be considered as indicative of a double dissociation in the proper nouns category, as there are already patients on record who have a selective deficit in retrieving proper nouns.

We report a quantitative investigation of three patients who presented with a profound prosopagnosia. They were tested on a series of tests of face perception, face recognition, and paired associate learning using faces. A patient with marked perceptual difficulties but no difficulty whatever in recognizing faces was tested as a control. The control patient's performance was as bad or worse on the tests of perception of faces, and it is concluded that impaired performance on tests of face perception does not contribute to difficulties in recognizing familiar faces. The major difference between the three prosopagnosic patients was the evidence of covert recognition in two of these cases but not in the third. We use this evidence to argue that the perceptual/mnestic distinction is an inappropriate classification and would suggest instead that the two types may be described in terms either of a disconnection of the face recognition units or of damage to the units themselves.