A Behavioral Approach to Treatment and Assessment of People with Disorders of Consciousness: The Response-contingent Stimulation Strategy

Response-contingent stimulation is a behavioral strategy used to improve the situation of patients with disorders of consciousness. Such strategy involves the presentation of brief periods (e.g., 10 to 15 s) of stimulation considered preferred by the patients, contingent on (immediately after) the emission of specific patients' responses. The aim is to help the patients learn the link between their responding and the preferred stimulation and thus learn to use their responding to access the stimulation in a self-determined/independent manner. Achieving these goals is considered important for the patients' recovery process and thus the response-contingent stimulation strategy that promotes such an achievement can be considered a valuable treatment approach. The same strategy combined with the use of periods of non-contingent stimulation (i.e., stimulation delivered independent of responding) may also serve as an assessment supplement with patients with apparent unresponsive wakefulness. The patients' increase in responding during the response-contingent stimulation and decline in responding during the non-contingent stimulation could be taken as a sign of discrimination between conditions, and possibly a sign of awareness of the immediate environmental situation, compatible with a diagnosis of minimally conscious state. This paper analyzes a number of studies aimed at using the response-contingent stimulation as a treatment strategy and a number of studies aimed at combining response-contingent stimulation with non-contingent stimulation for treatment and assessment purposes. The results of the studies are discussed in terms of the effectiveness, accessibility and affordability of the strategy. The need for new research (i.e., replication studies) is also pointed out

Long-term outcome following severe and very severe closed head injury during childhood

Includes bibliography.A retrospective follow-up study of nineteen Coloured subjects who sustained severe and very severe closed head injury in motor vehicle accidents while under the age of 15 years was carried out at a mean of 6,1 years post-injury. Each subject was neuropsychologically assessed using a battery of tests including those of general intellectual ability and motor, visuo-graphic, language and memory functioning. The performance of the head-injured group was compared with that of a control group-of ten normal subjects matched with the head-injured subjects for race and social class. In seventeen cases a detailed follow-up interview was obtained from one of the head-injured subject's primary caretakers. The results of the study suggest that global intellectual deficit is to be found most frequently where the duration of post-traumatic amnesia exceeds three weeks. Global impairment of IQ appears to be unlikely where post-traumatic amnesia lasts for less than one week. Subjects with a history of three weeks post- traumatic amnesia appear to be pervasively impaired in tests of neuropsychological function at long-term follow-up. Results indicate that post-traumatic amnesia of over one week but less than three weeks' duration is linked with long-term impairment in manual dexterity, motor-speed and precision, visuographic functioning and language production. It is suggested that post-traumatic amnesia of less than one week is linked with impaired motor-speed and precision and deficient language production. The most frequently reported changes following closed head injury include the development of headaches and motor weakness on one or other side of the body, irritability and impatience, anxiety, a tendency to withdraw, have a low tolerance for stress and impaired ability to attend. Forgetfulness, learning difficulties and scholastic failure also appear to be frequent sequelae. It is noted that, due to the small size of the sample, the results and conclusions are only suggestive of long-term outcome patterns in the Coloured South African who sustains severe or very severe closed head injury during childhood

Altered Self and Altered Self-Experience

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Development of Markerless Systems for Automatic Analysis of Movements and Facial Expressions: Applications in Neurophysiology

This project is focused on the development of markerless methods for studying facial expressions and movements in neurology, focusing on Parkinson’s disease (PD) and disorders of consciousness (DOC). PD is a neurodegenerative illness that affects around 2% of the population over 65 years old. Impairments of voice/speech are among the main signs of PD. This set of impairments is called hypokinetic dysarthria, because of the reduced range of movements involved in speech. This reduction can be visible also in other facial muscles, leading to a hypomimia. Despite the high percentage of patients that suffer from dysarthria and hypomimia, only a few of them undergo speech therapy with the aim to improve the dynamic of articulatory/facial movements. The main reason is the lack of low cost methodologies that could be implemented at home. DOC after coma are Vegetative State (VS), characterized by the absence of self-awareness and awareness of the environment, and Minimally Conscious State (MCS), in which certain behaviors are sufficiently reproducible to be distinguished from reflex responses. The differential diagnosis between VS and MCS can be hard and prone to a high rate of misdiagnosis (~40%). This differential diagnosis is mainly based on neuro-behavioral scales. A key role to plan the rehabilitation in DOC patients is played by the first diagnosis after coma. In fact, MCS patients are more prone to a consciousness recovery than VS patients. Concerning PD the aim is the development of contactless systems that could be used to study symptoms related to speech and facial movements/expressions. The methods proposed here, based on acoustical analysis and video processing techniques could support patients during speech therapy also at home. Concerning DOC patients the project is focused on the assessment of reflex and cognitive responses to standardized stimuli. This would allow objectifying the perceptual analysis performed by clinicians

The rate of decline of social skills across dementing and non-dementing individuals with intellectual disabilities: a longitudinal study

This study sought to establish rate of decline of adaptive skills in a population of individuals with intellectual disability (ID) and dementia compared to similar persons without dementia, as well as examining the variability of positive and negative social behaviors across diagnostic classes. Among the general population, differential rates of functional decline have been established for normal aging and dementia. This knowledge assists in making differential diagnoses of dementia, establishing prognosis, and long-term planning. For this study, participants in each group were individually matched for age, gender, Down’s syndrome status, and level of ID. Participants in the matched control group were screened for the presence of dementia with the Early Signs of Dementia Checklist (Visser & Kuilman, 1990). A 2 (groups) X 3 (measures) X 4 (repeated measures) Mixed Multivariate Analysis of Variance was completed to assess rate of decline within groups with the Vineland Adaptive Behavior Scales (Sparrow, Balla, & Cicchetti, 1984) and corresponding changes in positive and negative behaviors as measured by the Matson Evaluation of Social Skills for the Severely Retarded (Matson, 1995). Hypothesis 1 established that prior to a diagnosis of dementia groups were equivalent (F (1, 40) = 1.086, p = .304). Hypothesis 2 found no significant differences for adaptive behaviors, therefore rate of decline was not established. However, visual analysis of plotted means supports predicted decline in skills for both groups. Furthermore there were significant differences across time for positive social skills as measured with the MESSIER (F (3, 96) = 3.887, p = .011, â = .811). Hypothesis 3 yielded significant correlations between the VABS and the MESSIER Positive domains. Hypothesis 4 resulted in no significant correlations between the VABS and the MESSIER Negative skills. The findings of Hypotheses 2, 3, and 4 provide support for the diagnostic utility of the MESSIER with dementia. However, Hypothesis 4 did not support different variances of negative behaviors across diagnostic groups. This would suggest that the measure of negative behaviors is not supported as a diagnostic tool at this time

The Moral Status and Welfare of Patients Diagnosed as Vegetative With Covert Awareness

Several neuroimaging studies have demonstrated that a minority of patients diagnosed as being in the vegetative state are able to modulate their brain activity in response to the commands of researchers, thus demonstrating that they are ‘covertly aware.’ I examine the moral significance of this discovery, with a specific focus on the implications for patient welfare. I argue that the presence of awareness in these patients is important because it allows for the presence of sentience—the capacity for suffering and enjoyment—which I argue is a sufficient condition for moral status. Insofar as these patients have moral status, their interests matter morally; we have an obligation to give them proper consideration in our decision making. I present empirical evidence which supports the assumption that patients diagnosed as vegetative with covert awareness are sentient, and thus have moral status. I then consider an account of the welfare of these patients, which incorporates three traditional conceptions of welfare—hedonism, desire-satisfaction, and objective theories—and concludes that these patients are faring poorly, such that we may have a moral obligation to end their lives. I analyse and ultimately reject this conclusion. I argue that the application of traditional theories of welfare to these populations is impeded by a lack of knowledge of their subjective experiences, as well as challenges to the conceptions of welfare themselves. I then propose a novel approach for assessing the welfare of these patients, based on their subjective experiences. This approach involves extrapolating from the reported welfare interests of similar patient populations, as well as making plausible inferences about the residual cognitive capacities of these patients, based on the results of novel neuroimaging studies. Using these two sources of information, we can begin to construct a clearer picture of the welfare of these patients, and work to ensure that they have a decent quality of life

Factors influencing recovery from mild traumatic brain injury

Mild traumatic brain injury (mTBI) is an injury to the brain that may result in immediate and chronic changes in cognition, language, emotion, or social interactions. The current means of assessing brain dysfunction following mTBI do not appear to accurately capture how the brain will responds to this type injury; therefore, there has been a limited ability to determine accurate prognosis from mTBI. The purpose of this study was to determine if data gathered in the initial stages of injury following mTBI could predict recovery and if so, which factors were most predictive. Participants admitted to the hospital with mTBI were evaluated within 48 hours after injury and again at approximately one month after injury. Regression analysis was used to determine if initial GCS score, initial head CT results, cognitive performance on ImPACT testing, or APOE genotype were most effective in predicting 1-month functional outcome after mTBI. Additionally, independent t-test procedures were conducted to determine whether cognitive recovery would vary across APOEe4 carriers as compared to participants without an APOEe4 allele. Results showed that none of the study variables significantly predicted one month GOS-E scores or DRS scores, however, cognitive differences were identified when APOE groups were compared. Participants who were noncarriers of an APOEe4 allele had significantly slower reaction times compared to APOEe4 carriers. Participants who were homozygous APOEe4 carriers had significantly lower instances of impulsivity than participants with other genotype combinations

Investigating the Comprehensive Inventory of Thriving (CIT) as a rehabilitation outcome measure

Reliable and valid outcome measures are needed in community rehabilitation settings following acquired neurological injury. The Comprehensive Inventory of Thriving (CIT) (Su, Tay and Diener, 2013) was investigated for this purpose. The CIT is a 54 item self-report measure that provides 18 subscales and seven main scales of thriving: Relationships, Engagement, Mastery, Autonomy, Meaning, Optimism and Subjective Well-being. Participants (n=76) were administered the CIT on admission to a community rehabilitation service. The mean age of participants was 54.8 (SD = 17.7), with 43% being male. The main diagnostic groups were cerebrovascular disease (28%), traumatic brain injury (17%) and Parkinson's disease (12%). Internal consistency was moderate to high (α =.6 to .9) for all subscales with the exception of Support (Relationships) and Skills (Mastery); and high (α=.79-.93) for all indexes with the exception of Subjective Wellbeing. Correlational analyses supported the scale groupings. However, the subscales of Support (Relationships) and Skills (Mastery) did not correlate significantly with any subscales. Additionally the Subjective Well-being scale should not be calculated, but instead its three subscales (Negative Feelings, Life Satisfaction, Positive Feelings) used individually. In terms of demographic variables, there were no significant gender differences on CIT scales. Age had low correlations with two Relationships subscales only (Trust r=.23, p=.04; Loneliness r=-.25, p=.03). Diagnostic group minimally influenced CIT scores. Significant between-group differences were only found for Accomplishment (Mastery), with post-hoc analyses indicating higher levels for the cerebrovascular group. The CIT shows considerable promise in rehabilitation outcomes as a reliable and valid multi-component measure of wellbeing