Background: Motor dysfunction in the contralateral hand has been well characterised after stroke. The ipsilateral hand has received less attention, yet may provide valuable insights into the structure of the motor system and the nature of the recovery process. By tracking motor function of both hands beginning in the acute stroke period in patients with cortical versus subcortical lesions, we sought to understand the functional anatomy of the ipsilateral deficit. Methods: We examined 30 patients with first-ever unilateral hemiparetic stroke, 23 with subcortical lesions affecting the corticospinal tract, seven with cortical involvement. Patients performed hand dynamometry and the 9-Hole Peg Test (9HPT) with each hand at 24–48 h, 1 week, 3 months and 1 year after stroke. Linear regression was used to compare the two different motor tasks in each hand. Repeated measures ANOVA was used to compare recovery rates of the two tasks in the first 3 months. Results: Ipsilateral 9HPT scores averaged z = −7.1, −3.6, −2.5 and −2.3 at the four time points whereas grip strength was unaffected. The initial degree of impairment of grip strength in the contralateral hand did not correlate with the degree of impairment of 9HPT in either the contralateral or ipsilateral hand (r = 0.001, p = 0.98), whereas the initial degree of impairment of 9HPT in the contralateral hand correlated with the degree of impairment of 9HPT in the ipsilateral hand (r = 0.79, p = 0.035). The rate of recovery also differed for the two tasks (p = 0.005). Conclusion: Ipsilateral motor deficits are demonstrable immediately after stroke and extend into the subacute and chronic recovery period. Dissociation between grip strength and dexterity support the notion that dexterity and grip strength operate as anatomically and functionally distinct entities. Our findings in patients with subcortical lesions suggest that the model of white matter tract injury needs to be refined to reflect the influence of a subcortical lesion on bi-hemispheral cortical networks, rather than as a simple “severed cable” model of disruption of corticofugal fibres. Our data have implications for both stroke clinical trials and the development of new strategies for therapeutic intervention in stroke recovery.

To evaluate the contribution of social communication abilities and affective/behavioral functioning to social integration outcomes for persons with traumatic brain injury (TBI). Prospective cohort study. A total of 184 adults with TBI (72.8% men) evaluated at least 6 months postdischarge from acute care or inpatient rehabilitation hospitals and after living at least 3 months in the community postdischarge (Mean = 7.84 months postinjury). La Trobe Communication Questionnaire (LCQ), Assessment of Interpersonal Problem-Solving Skills(AIPSS), Affective Behavioral subscale From the Problem Checklist of the Head Injury Family Interview (AB-HIFI), Craig Handicap Assessment and Reporting Technique-Short Form Social Integration subscale (CHART-SF-SI), Community Integration Questionnaire Social Integration subscale (CIQ-SI). Social communication measures (LCQ, AIPSS) and self-reported behavioral functioning (AB-HIFI) contributed significantly to concurrently measured social integration outcomes after controlling for demographic and injury-related variables. Separate hierarchical multiple regression analyses revealed that social communication and behavioral variables accounted for 11.3% of variance in CIQ-SI and 16.3% of variance in CHART-SF-SI. Social communication abilities and affective/behavioral functioning make a substantial contribution to social integration outcomes after TBI. The implications of such evidence for clinical assessment and intervention are discussed.

Background and objective. Visual restoration therapy is a home-based treatment program intended to expand visual fields of hemianopic patients through repetitive stimulation of the borderzone adjacent to the blind field. We hypothesized that the training itself would induce visual field location-specific changes in the brain's response to stimuli, a phenomenon demonstrated in animal experiments but never in humans with brain injury. Methods. Six chronic right hemianopic patients underwent functional magnetic resonance imaging (fMRI)—responding to stimuli in the trained visual borderzone versus the nontrained seeing field before and after 1 month of visual restoration therapy. Spatially normalized fMRI time-series data were analyzed in a fixed-effects group analysis comparing blood oxygen level dependent (BOLD) activity in the borderzone versus seeing location at baseline and at 1 month. Percent BOLD change was measured to determine each condition's contribution to the time-by-condition interaction. Results. There was a significant time by condition interaction manifested as increased BOLD activity for borderzone detection relative to seeing detection after the first month of therapy, which correlated with a relative improvement in response times in the borderzone location out-of-scanner. The right inferior and lateral temporal, right dorsolateral frontal, bilateral anterior cingulate, and bilateral basal ganglia showed the greatest response. Conclusion. Visual restoration therapy appears to induce an alteration in brain activity associated with a shift of attention from the nontrained seeing field to the trained borderzone. The effect appears to be mediated by the anterior cingulate and dorsolateral frontal cortex in conjunction with other higher order visual areas in the occipitotemporal and middle temporal regions. Demonstration of a visual field—specific training effect on brain activity provides an important starting point for understanding the potential for visual therapy in hemianopia.

This study examined the course of clinically significant cognitive change in hematopoietic stem cell transplant (HSCT), using a Reliable Change Index (RCI). Neuropsychological evaluations were administered to 117 patients before HSCT. Thirty-three received subsequent evaluations 6 and 28 weeks later. Of 117 patients, 39% were classified as impaired before HSCT. Of the 33 receiving subsequent evaluations, 47% showed reliable decline at 6-weeks; of these, 33% showed reliable decline again at 28-weeks. Mood and QOL did not account for declines. Verbal learning, psychomotor speed, and executive function showed greatest vulnerability to pre-HSCT impairment, and verbal learning showed greatest likelihood of further, subsequent decline. In conclusion, a subgroup of patients showed cognitive impairment before HSCT, indicating that factors other than HSCT contributed to cognitive deficits. Another subgroup showed further decline after HSCT. This study demonstrated the utility of the RCI in describing cognitive change in HSCT patients.

This study aimed to empirically evaluate the hierarchical structure of the Coma Recovery Scale-Revised (CRS-R) rating scale categories and their alignment with the Aspen consensus criteria for determining disorders of consciousness (DoC) following a severe brain injury. CRS-R data from 262 patients with DoC following a severe brain injury were analyzed applying the partial credit Rasch Measurement Model. Rasch Analysis produced logit calibrations for each rating scale category. Twenty-eight of the 29 CRS-R rating scale categories were operationalized to the Aspen consensus criteria. We expected the hierarchical order of the calibrations to reflect Aspen consensus criteria. We also examined the association between the CRS-R Rasch person measures (indicative of performance ability) and states of consciousness as determined by the Aspen consensus criteria. Overall, the order of the 29 rating scale category calibrations reflected current literature regarding the continuum of neurobehavioral function: category 6 “Functional Object Use” of the Motor item was hardest for patients to achieve; category 0 “None” of the Oromotor/Verbal item was easiest to achieve. Of the 29 rating scale categories, six were not ordered as expected. Four rating scale categories reflecting the Vegetative State (VS)/Unresponsive Wakefulness Syndrome (UWS) had higher calibrations (reflecting greater neurobehavioral function) than the easiest Minimally Conscious State (MCS) item (category 2 “Fixation” of the Visual item). Two rating scale categories, one reflecting MCS and one not operationalized to the Aspen consensus criteria, had higher calibrations than the easiest eMCS item (category 2 “Functional: Accurate” of the Communication item). CRS-R person measures (indicating amount of neurobehavioral function) and states of consciousness, based on Aspen consensus criteria, showed a strong correlation (r _s = 0.86; p < 0.01). Our study provides empirical evidence for revising the diagnostic criteria for MCS to also include category 2 “Localization to Sound” of the Auditory item and for Emerged from Minimally Conscious State (eMCS) to include category 4 “Consistent Movement to Command” of the Auditory item.

Objective: To determine whether visual field expansion occurs with visual restoration therapy (VRT), using fundus-controlled microperimetry to assess visual fields. Design: This longitudinal cohort analysis assesses patients’ visual fields before and after visual restoration therapy using microperimetry and standard high-resolution perimetry. Subjects: Seven patients with stroke-induced homonymous field cuts were studied. Intervention: Visual restoration therapy is a computerized, home-based treatment aimed at reducing the size of the visual field defect of stroke patients with hemianopia through repetitive stimulation of the visual borderzone adjacent to the blind field. During twice-daily therapy for three months patients maintain central fixation while responding to eccentrically placed stimuli in the visual borderzone. The programme is adjusted monthly to changes in the patient’s visual field. Controversy exists as to whether expansion of visual fields measured at home with high-resolution perimetry is due to inadvertent eye movements and therefore would overrepresent the treatment’s effect. Main measures: Microperimentry uses an infrared camera to track retinal vessels so that any shift or movement between the reference image and the real-time fundus image corrects the stimulus position, thus delivering stimuli to known retinal locations, and allowing accurate assessment of visual fields independent of eye movements. Results: There was an average improvement in stimulus detection rate by microperimetry of 12.5% (range —1.4% to 38.9%, P =0.033). Six of 7 patients had ≥ 3% improvement in stimulus detection by home-based perimetry. Conclusion: Our results demonstrate modest but real expansion in visual fields following visual restoration therapy which is not due to eye movements.