Book

Functional Neurology, Rehabilitation, and Ergonomics, Volume 4, Issue 4

Book

Functional Neurology, Rehabilitation, and Ergonomics, Volume 4, Issue 4

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Conference Paper
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Infants have a sophisticated behavioral and cognitive repertoire suggestive of a capacity for conscious reflection. Demonstrating consciousness in infants is challenging and prenatally even more so, mainly because infants cannot report their thoughts and behavioral measurements in the fetus is difficult. Such evaluations of consciousness are even more difficult in the prenatal and antenatal infant. The importance of being able to evaluate conscious reflection in prenatal, infancy and early childhood is important as numerous treatment decisions are based on its adequate assessment. Consciousness requires a sophisticated network of highly interconnected components. Its physical substrate, the thalamo-cortical complex, with its highly elaborate content, begins to be in place between the 24th and 28th week of gestation. Roughly two months later synchrony of the electro-encephalographic (EEG) rhythm across both cortical hemispheres signals the onset of global neuronal integration. Thus, many of the circuit elements necessary for consciousness are in place by the third trimester. By this time, preterm infants can survive outside the womb under proper medical care. As it is easier to observe and interact with a preterm baby than with a fetus of the same gestational age in the womb, the fetus is often considered to be like a preterm baby. This notion disregards the unique uterine environment: suspended in a warm and dark cave, connected to the placenta that pumps blood, nutrients and hormones into its growing body and brain. Invasive experiments in rat and lamb pups and observational studies using ultrasound and electrical recordings in humans show that the third-trimester fetus is almost always in one of two sleep states. Called active and quiet sleep, these states can be distinguished using electroencephalography. Their different EEG signatures go hand in hand with distinct behaviors: breathing, swallowing, licking, and moving the eyes but no large-scale body movements in active sleep; no breathing, no eye movements and tonic muscle activity in quiet sleep. These stages correspond to rapid-eye-movement (REM) and slow-wave sleep common to all mammals. In late gestation the fetus is in one of these two sleep states 95 percent of the time, separated by brief transitions. Fascinating is the discovery that the fetus is actively sedated by the low oxygen pressure (equivalent to that at the top of Mount Everest), the warm and cushioned uterine environment and a range of neuro-inhibitory and sleep-inducing substances produced by the placenta and the fetus itself: adenosine; two steroidal anesthetics, allopregnanolone and pregnanolone; one potent hormone, prostaglandin D2; and others. The role of the placenta in maintaining sedation is revealed when the umbilical cord is closed off while keeping the fetus adequately supplied with oxygen. We can conclude that the fetus is asleep while its brain matures. We will examine the parallelism of brain and cognitive development until both the physiological and cognitive aspects of awake and aware behavior, (i.e. consciousness) is understood. The importance of understanding these issues provides us with a context for treatment decisions and for understanding the nature of functional connectivities.
Conference Paper
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INTRODUCTION: Consciousness requires a sophisticated network of highly interconnected components. Its physical substrate, the thalamo-cortical complex, allows for its basis to be in place between the 24th-28th gestational week. Roughly 2 months later, bi-hemispheric EEG synchrony signals the onset of global neuronal integration. Thus, many of the circuits necessary for consciousness are in place by the 3rd trimester. Now, pre-term infants can survive outside the womb. It is also easier to interact with a preterm infant than with a fetus of the same gestational age in the womb. The notion that the fetus is like a preterm baby disregards the unique uterine environment. Invasive experiments in rat and lamb pups, ultrasound observational studies, and electrical recordings in humans show that 3rd-trimester fetuses are almost always in one of two sleep states, active or quiet, distinguished by different EEG signatures. Fascinating is that the fetus is actively sedated by the low oxygen pressure, the warm and cushioned uterine environment, and a range of neuroinhibitory and sleep-inducing substances produced by the placenta and the fetus itself: adenosine; two steroidal anesthetics, allopregnanolone and pregnanolone; one potent hormone, prostaglandin D2 and others. OBJECTIVES: To outline the nature of functional disconnectivities in fetuses and neonates and how rapid frontal lobe growth and functional connection development is associated with consciousness in early life. METHODOLOGY: The literature on fetal responsivity as well as electro-physiology-based studies of pre- and full-term infants’ electrophysiological performance is examined. RESULTS: The pre- and post-natal development of functional connectivities and their association with the reduction of primitive reflexes will be demonstrated along with increases in cognitive performance including attention and language.CONCLUSIONS: The development of consciousness (awake and aware) is consistent with post-partum status, brain weight,functional connectivity, and frontal lobe development.
Article
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Background: Persistent vegetative states (PVS) and locked-in syndrome (LIS) are well differentiated disorders of consciousness that can be reached after a localized brain injury in the brainstem. The relations of the lesion topography with the impairment in the whole-brain architecture and functional disconnections are poorly understood. Methods: Two patients (PVS and LIS) and 20 age-matched healthy volunteers were evaluated using diffusion tensor imaging (DTI). Anatomical network was modeled as a graph whose nodes are represented by 71 brain regions. Inter-region connections were quantified through Anatomical Connection Strength (ACS) and Density (ACD). Complex networks properties such as local and global efficiency and vulnerability were studied. Mass univariate testing was performed at every connection using network based statistic approach. Results: LIS patients’ network showed significant differences from controls in the brainstem-thalamus-frontal cortex circuitry, while PVS patients showed a widespread disruption of anatomical connectivity in both hemispheres. Both patients showed a reorganization of network attributes, with decreased global and local efficiency, significantly more pronounced in PVS. Conclusions: Our results suggest that DTI-based network connectivity combined with graph theory is useful to study the long-range effect of confined injuries and the relationship to the degree of consciousness impairment, underlying PVS and LIS.
Article
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Little of the 150 years of research in Cognitive Neurosciences, Human Factors, and the mathematics of Production Management have found their way into educational policy and certainly not into the classroom or in the production of educational materials in any meaningful or practical fashion. While more mundane concepts of timing, sequencing, spatial organization, and Gestalt principles of perception are well known and applied, as well as the maintenance of simplistic notions of developmental brain organization and hemisphericity for language rather than the neurophysiology of embodied language, these concepts still inform pre-K-3 curriculum and clinical neurological practice in both the diagnostic and therapeutic modalities. The paper overviews the science of human physiologic efficiencies to develop a fundamental understanding that the concept of localization of function in the brain is a just reflection of plasticity and required for optimized function, but understanding brain function by that alone would obscure the understanding of the education and rehabilitation process from early childhood through the older years. Diagnostic and therapeutic systems need to address pathways in the brain and their changes as a result of intervention rather than examine more static notions of localized function.
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We model the brainstem as two layers of purely excitatory and inhibitory cells, with a time delay in transmission of information between the layers. The response to a localized afferent impulse is a strong function of this inhibitory delay; at first showing increased amplification as the delay increases, but at larger delays showing increased convection away from the impulse location. These features are consistent with the function of the brainstem in regulating attentional levels, and have possible implications for the understanding of higher brain mechanisms
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Exposure to musical training in childhood has been studied extensively as models of neuroplasticity. The long-term training and continued practice of complex bi-manual motor sequences are highly associated with changes in brain structure and cortical motor maps compared with individuals without such training. We know that the anterior corpus callosum, with fibers connecting frontal motor regions and pre-frontal areas coordinating bimanual activity is larger in musicians who started training prior to age seven than in either controls. Additionally, auditory experiences during early postnatal development shape the functional neurology of auditory cortical representation resulting in increased functional areas of the auditory cortex. The developing brain is far more plastic than the adult brain explaining the results that we see in recovery of function after brain damage in childhood, neuronal connections are being continuously remodeled by experience, enrichment, and by performance on specific and complex movements during motor and cognitive learning. New skill acquisition, present to a much greater degree in childhood is highly associated with structural changes in the intracortical and subcortical networks in motor skill training. The relationship between music, visual, and spatial training on brain organization and plasticity are discussed with applications for solutions to the rehabilitation of the brain impaired.
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An application is discussed that uniquely integrates auditory and visual stimulation with force modulation. It was developed to answer unmet needs of Occupational Therapists, Art Therapists and Music Therapists, who treat developmental disorders, as well as therapists specializing in neurological aftercare and hand rehabilitation. Squeezing the special pressure sensitive grip sensors causes the application to generate sounds, voices and music, along with captivating imagery, based on the level of force applied and according to the therapy objective. The described system’s development was guided by the assumption that the human brain intuitively associates sound pitch with tension. The system uses the association of pitch with muscle tension to simplify the creation of music by transforming grip-induced muscle tension to musical phrases which provides a new therapy option based on sensory integration. The grip force sensors’ sensitivity and responsiveness can be adjusted to the patient’s motor skills, thus making the transformation more “natural.”. Even patients suffering severe disabilities find the grip squeezing force and the produced sounds highly correlated in a direct and natural manner. The musicality and continuity of the musical creation highly depends on the patient’s skills, Farah Jubran and Gerry Leisman 214 pace and the system’s speed of response. The system’s “on-the-fly tuning” helps matching the system tempo with the patient’s pace, accelerating or decelerating speed, to determine the desired level of challenge and gratification during the treatment. The system helps in reducing passivity and increasing motivation and awareness through the sense of control granted to the patient playing the tool, as well as in reducing involuntary movement. In addition, the system allows the creation of personalized treatment programs that make use of meaningful images or photos from the patient and his/her world and surroundings.
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Background: The neuroimaging findings of acute central transtentorial herniation are well documented; however survival in this condition is unusual. Case report: A 20-year-old woman developed central transtentorial herniation secondary to acute hydrocephalus after the obstruction of a ventriculo-peritoneal shunt inserted for the treatment of chronic hydrocephalus. The surgical ventricular drainage was delayed, and after being in coma for several days, the patient was finally diagnosed as being in a persistent vegetative state (PVS). The neuroimaging studies revealed a severe bilateral infarction of thalamus, subthalamus, mesocephalus and left superior cerebellum, a distribution suggestive of ischemia affecting perforating arteries arising from the top of the basilar artery and proximal segment of the posterior cerebral artery, as well as from the superior cerebellar artery. Conclusion: Survivors of central transtentorial herniation can sustain severe damage to the thalamus and mesencephalon, despite a relative preservation of the neocortex, leading to a PVS syndrome.
Conference Paper
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Recent spectacular advances in neurosciences have stimulated the hope that the application of our understanding that it is no longer about cerebral asymmetries and simplistic left-right differences but more complex applications of networks, and communication system principles that have led to newly developed concepts and findings that have not, as yet, found there way into the classroom. We are at the cusp of developing breakthrough concepts in the understanding of how children learn in the formal setting of the classroom in the context of brain function and how that function can be modified. We believe that the techniques and knowledge of neuroscience as well as Human Factors and Industrial Engineering notions of efficiency and production management can provide a service to education at all stages throughout life. Although the human brain - the most crucial part of the anatomy - is the most complex mechanism known to man, it is now being analyzed in ways that are clearly significant for education. Recent research on the human brain has provided data relevant to understanding the processes of human learning and therefore to improving methods of teaching. Most currently prevailing patterns of education are heavily biased to wards left cerebral functioning and are antithetical to right cerebral functioning. Reading, writing and arithmetic are all logical linear processes, and for most of us are fed into the brain through our right hand. Most educational policies have tended to aggravate and prolong this one-sidedness. There is a kind of damping down of fantasy, imagination, clever guessing, and visualization in the interests of rote-learning, reading, writing, and arithmetic. Great emphasis is placed upon being able to say what one has on one's mind clearly and precisely the first time. The atmosphere emphasizes intra-verbal skills, ”Using words to talk about words that refer to still other words" What emerges as the central proposition of this paper is that (A) the examination and study of regional cerebral differences in brain function as a way of explaining and evaluating the learning process within the educational system is a non-starter. (B) The evaluation of students by standardized aptitude and achievement tests is not sufficient although probably still necessary and (C) the educational systems would be better to examine student performance and teach towards “cognitive efficiency” rather than simply mastery v. non-mastery with methods that employ both psychophysics that examine person-environment interaction and mathematical means of examining optimization and the strategy used to get there as well as how far or close a student is functioning from a mathematically derived optimization regression line or, in fact, how quickly the learner is progressing in that direction. Educators, although perhaps not palatable to conceive of early childhood education as such, are producing a product and production management techniques should be useful for evaluating not just the product but the process or “manufacture” of that product as well.
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We studied autistics by quantitative EEG spectral and coherence analysis during three experimental conditions: basal, watching a cartoon with audio (V–A), and with muted audio band (VwA). Significant reductions were found for the absolute power spectral density (PSD) in the central region for delta and theta, and in the posterior region for sigma and beta bands, lateralized to the right hemisphere. When comparing VwA versus the V–A in the midline regions, we found significant decrements of absolute PSD for delta, theta and alpha, and increments for the beta and gamma bands. In autistics, VwA versus V–A tended to show lower coherence values in the right hemisphere. An impairment of visual and auditory sensory integration in autistics might explain our results.
Conference Paper
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Survival of the organism in nature is dependent on its adaptational ability to its external environment. Circadian rhythms are classified by periodicity that includes endogenous or exogenous elements the differences between which are a function of the synchronicity of the organism’s pacemaker function. After birth, the infant is exposed to 24-hours of photoperiodic stimulation due to the nature of intensive-care. In the present study, we examined the development of the physiological parameters of respiratory (RSP) as well as heart rate (PLS) in pre-term infants who were exposed to constant non-periodic illumination. Body Mass of the pre-term infants was measured and ranged between 670 grams-1720 g. and measurements of these pre-term infants of 25-35 gestational weeks were taken immediately after birth. Data were collected by physiological intensive care monitoring systems on a 24-hour/day basis for six weeks.
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Brains are built over time, from the bottom up with intra-regional connections being developed throughout the lifespan but intensely during early childhood. Early experi¬ences affect the quality of brain architecture by es¬tablishing either a sturdy or a fragile foundation for all of the learning, health and behavior that follows. After the rapid proliferation of connections in the preschooler, these connections are reduced through pruning, thereby optimizing brain circuitry. Sensory pathways like those for basic vision and hearing are the first to develop, followed by early language skills and higher cognitive functions. Connections proliferate and prune in a prescribed order, with later, more complex brain circuits built upon earlier, simpler circuits. Genetics and interactive experience shape brain development. Inadequate or inappropriate early experiences will affect the circuitry and architecture of the brain associated with disparities in learning, behavior and development
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Abstract The EEG has not been comprehensively used to study the brain function in Autistic Spectrum Disorder (ASD) patients. Therefore, the researchers recently developed a specifically designed software (EEGConn) to explore brain function based on advanced algorithms to explore EEG activity. They studied a group of 14 righthanded autistic patients with age 70.3±29.32 and 14 healthy subjects with IQs over 85. All recordings were performed with the subjects lying in a recumbent position, in eye opened condition; EEG ...
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We report unusual twisting of the brainstem in MRI tractography in a patient who survived a traumatic brain injury with upper spinal dislocation. A 39-year-old male patient involved in a highspeed car accident was admitted in coma on February 2003. He had a Glasgow Coma Scale of 4, respiratory arrhythmia and tetraplegia. Four weeks later he was diagnosed as being in a persistent vegetative state (PVS). Our group evaluated him for first time in 2010. The patient was then in a minimally conscious state (MCS), with a limited but clear evidence of awareness of the environment, based on a reproducible gestural response following simple commands and visual pursuit of relatives and other persons in his room. He maintained a severe tetraplegia, hyperreflexia, and bilateral Babinski sign. Neuroimaging studies (Figure 1) performed according to our protocol for the assessment of PVS/MCS,[1,2] demonstrated a severe atrophic and twisted brainstem. There was an MRI-T2 hyperintensity in the lower part of the medulla oblongata that suggested the presence of an old infarct, probably due to an ischemic and/or hemorrhagic insult because of the compression of the brainstem. MRI-Tractography revealed brainstem long tracts twisting. In order to have a better visualization of bone abnormali In our patient hypoxic encephalopathy secondary to acute respiratory insufficiency was surely the cause of his chronic consciousness disorder.[1,2] Probably his critical condition, and the needs of life support protocols upon arrival to the intensive care, hampered the with upper spinal dislocation diagnosis,[3-5] leading to a lack of radiological evidence, or due to the presence of additional injuries where a clinical examination is impossible. The demonstration of brainstem twisting instead of section in MRI-Tractography has is an unusual neuroimaging finding, and scientifically highlights the neuroimaging findings in this patient who survived severe upper spinal dislocation
Article
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Spectral analysis (SA) has been extensively applied to the assessment of heart rate variability. Traditional methods require the transformation of the original non-uniformly spaced electrocardiogram RR interval series into regularly spaced ones using interpolation or other approaches. The Lomb-Scargle (L-S) method uses the raw original RR series, avoiding different artifacts introduced by traditional SA methods, but it has been scarcely used in clinical settings. An RR series was recorded from 120 healthy participants (17–25 years) of both genders during a resting condition using four SA methods, including the Classic modified periodogram, the Welch procedure, the autoregressive Burg method and the L-S method. The efficient implementation of the L-S algorithm with the added possibility of the application of a set of options for the RR series pre-processing developed by Eleuteri et al., and also the results obtained in this study, show that the L-S method can be a good choice for future clinical studies. The L-S method seems particularly useful when the heart rates of studied participants will be below 60 or over 120 beats per minute. Nevertheless, it is important to the development of a smoothing procedure for the L-S spectra to avoid the picky behavior of the L-S power spectrum. The implementation of the L-S algorithm used in this study has been recently published by other authors included in our references, and brings some particular filtering features. The results obtained, comparing the four spectral methods, show that this implementation seems particularly useful when the heart rates of studied participants will be below 60 or over 120 beats per minute. Nevertheless, it is important to recommend for all existing L-S software implementations, the development of a smoothing procedure to avoid the picky behavior of the L-S power spectrum.
Conference Paper
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Background: Persistent vegetative states (PVS) and locked-in syndrome (LIS) are well-differentiated disorders of consciousness that can be reached after a localized brain injury in the brainstem. The relations of the lesion topography with the impairment in the whole-brain architecture and functional disconnections are poorly understood. Methods: Two patients (PVS and LIS) and 20 age-matched healthy volunteers were evaluated using diffusion tensor imaging (DTI). Anatomical network was modeled as a graph whose nodes are represented by 71 brain regions. Inter-region connections were quantified through Anatomical Connection Strength (ACS) and Density (ACD). Complex networks properties such as local and global efficiency and vulnerability were studied. Mass univariate testing was performed at every connection using network based statistic approach. Results: LIS patients' network showed significant differences from controls in the brainstem-thalamus-frontal cortex circuitry, while PVS patients showed a widespread disruption of anatomical connectivity in both hemispheres. Both patients showed a reorganization of network attributes, with decreased global and local efficiency, significantly more pronounced in PVS.
Article
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Pseudobulbar affect (PBA) is a common manifestation of brain pathology associated with many neurological diseases, including amyotrophic lateral sclerosis, Alzheimer's disease, stroke, multiple sclerosis, Parkinson's disease, and traumatic brain injury. PBA is defined by involuntary and uncontrollable expressed emotion that is exaggerated and inappropriate, and also incongruent with the underlying emotional state. Dextromethorphan/quinidine (DM/Q) is a combination product indicated for the treatment of PBA. The quinidine component of DM/Q inhibits the cytochrome P450 2D6-mediated metabolic conversion of dextromethorphan to its active metabolite dextrorphan, thereby increasing dextromethorphan systemic bioavailability and driving the pharmacology toward that of the parent drug and away from adverse effects of the dextrorphan metabolite. Three published efficacy and safety studies support the use of DM/Q in the treatment of PBA; significant effects were seen on the primary end point, the Center for Neurologic Study-Lability Scale, as well as secondary efficacy end points and quality of life. While concentration-effect relationships appear relatively weak for efficacy parameters, concentrations of DM/Q may have an impact on safety. Some special safety concerns exist with DM/Q, primarily because of the drug interaction and QT prolongation potential of the quinidine component. However, because concentrations of dextrorphan (which is responsible for many of the parent drug's side effects) and quinidine are lower than those observed in clinical practice with these drugs administered alone, some of the perceived safety issues may not be as relevant with this low dose combination product. However, since patients with PBA have a variety of other medical problems and are on numerous other medications, they may not tolerate DM/Q adverse effects, or may be at risk for drug interactions. Some caution is warranted when initiating DM/Q treatment, particularly in patients with underlying risk factors for torsade de pointes and in those receiving medications that may interact with DM/Q.
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To make evidence-based recommendations for screening, diagnosing, and treating psychiatric disorders in individuals with multiple sclerosis (MS). We reviewed the literature (1950 to August 2011) and evaluated the available evidence. Clinicians may consider using the Center for Neurologic Study Emotional Lability Scale to screen for pseudobulbar affect (Level C). Clinicians may consider the Beck Depression Inventory and a 2-question tool to screen for depressive disorders and the General Health Questionnaire to screen for broadly defined emotional disturbances (Level C). Evidence is insufficient to support/refute the use of other screening tools, the possibility that somatic/neurovegetative symptoms affect these tools' accuracy, or the use of diagnostic instruments or clinical evaluation procedures for identifying psychiatric disorders in MS (Level U). Clinicians may consider a telephone-administered cognitive behavioral therapy program for treating depressive symptoms (Level C). Although pharmacologic and nonpharmacologic therapies are widely used to treat depressive and anxiety disorders in individuals with MS, evidence is insufficient to support/refute the use of the antidepressants and individual and group therapies reviewed herein (Level U). For pseudobulbar affect, a combination of dextromethorphan and quinidine may be considered (Level C). Evidence is insufficient to determine the psychiatric effects in individuals with MS of disease-modifying and symptomatic therapies and corticosteroids; risk factors for suicide; and treatment of psychotic disorders (Level U). Research is needed on the effectiveness in individuals with MS of pharmacologic and nonpharmacologic treatments frequently used in the non-MS population.
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Objective: To study the Zolpidem arousing effect in persistent vegetative state (PVS) patients combining clinical evaluation, autonomic assessment by heart rate variability (HRV), and EEG records. Methods: We studied a group of 8 PVS patients and other 8 healthy control subjects, matched by age and gender. The patients and controls received drug or placebo in two experimental sessions, separated by 10-14 days. The first 30 minutes of the session were considered the basal record, and then Zolpidem was administered. All participants were evaluated clinically, by EEG, and by HRV during the basal record, and for 90 minutes after drug intake. Results: We found in all patients, time-related arousing signs after Zolpidem intake: behavioral (yawns and hiccups), activation of EEG cortical activity, and a vagolytic chronotropic effect without a significant increment of the vasomotor sympathetic tone. Conclusions: We demonstrated time-related arousing signs after Zolpidem intake. We discussed possible mechanisms to explain these patho-physiological findings regarding EEG cortical activation and an autonomic vagolytic drug effect. As this autonomic imbalance might induce cardiocirculatory complications, which we didn't find in any of our patients, we suggest developing future trials under control of physiological indices by bedside monitoring. However, considering that this arousing Zolpidem effect might be certainly related to brain function improvement, it should be particularly considered for the development of new neuro-rehabilitation programs in PVS cases. According to the literature review, we claim that this is the first report about the vagolitic effect of Zolpidem in PVS cases.
Article
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Background: Pseudobulbar affect (PBA) is a neurological condition characterized by involuntary, sudden, and frequent episodes of laughing and/or crying, which can be socially disabling. Although PBA occurs secondary to many neurological conditions, with an estimated United States (US) prevalence of up to 2 million persons, it is thought to be under-recognized and undertreated. The PBA Registry Series (PRISM) was established to provide additional PBA symptom prevalence data in a large, representative US sample of patients with neurological conditions known to be associated with PBA. Methods: Participating clinicians were asked to enroll ≥20 consenting patients with any of 6 conditions: Alzheimer's disease (AD), amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), Parkinson's disease (PD), stroke, or traumatic brain injury (TBI). Patients (or their caregivers) completed the Center for Neurologic Study-Lability Scale (CNS-LS) and an 11-point scale measuring impact of the neurological condition on the patient's quality of life (QOL). Presence of PBA symptoms was defined as a CNS-LS score ≥13. Demographic data and current use of antidepressant or antipsychotic medications were also recorded. Results: PRISM enrolled 5290 patients. More than one third of patients (n = 1944; 36.7%) had a CNS-LS score ≥13, suggesting PBA symptoms. The mean (SD) score measuring impact of neurological condition on QOL was significantly higher (worse) in patients with CNS-LS ≥13 vs <13 (6.7 [2.5] vs. 4.7 [3.1], respectively; P<0.0001 two-sample t-test). A greater percentage of patients with CNS-LS ≥13 versus <13 were using antidepressant/antipsychotic medications (53.0% vs 35.4%, respectively; P<0.0001, chi-square test). Conclusions: Data from PRISM, the largest clinic-based study to assess PBA symptom prevalence, showed that PBA symptoms were common among patients with diverse neurological conditions. Higher CNS-LS scores were associated with impaired QOL and greater use of antipsychotic/antidepressant medications. These data underscore a need for greater awareness, recognition, and diagnosis of PBA.
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Regular physical activity is associated with enhanced plasticity in the motor cortex but the effect of a single session of aerobic exercise on neuroplasticity is unknown. The aim of this study was to compare corticospinal excitability and plasticity in the upper limb cortical representation following a single session of lower limb cycling at either low or moderate intensity, or a control condition. We recruited 25 healthy adults to take part in three experimental sessions. Cortical excitability was examined using transcranial magnetic stimulation to elicit motor evoked potentials (MEPs) in the right first dorsal interosseus (FDI) muscle. Levels of serum brain-derived neurotrophic factor (BDNF) and cortisol were also assessed. Following baseline testing, participants cycled on a stationary bike at a workload equivalent to 57% (low intensity, 30 mins) or 77% age-predicted maximal heart rate (moderate intensity, 15 minutes), or a seated control condition. Neuroplasticity within the primary motor cortex was examined using a continuous Theta Burst Stimulation (cTBS) paradigm. We found that exercise did not alter cortical excitability. Following cTBS, there was a transient inhibition of FDI MEPs during control and low intensity conditions but this was only significantly different following the low intensity state. Moderate intensity exercise alone increased serum cortisol levels, but BDNF levels did not increase across any condition. In summary, low intensity cycling promoted the neuroplastic response to cTBS within the motor cortex of healthy adults. These findings suggest that light exercise has the potential to enhance the effectiveness of motor learning or recovery following brain damage.
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Traumatic brain injury (TBI) is a critical public health and socio-economic problem throughout the world. Reliable quantification of the burden caused by TBI is difficult owing to inadequate standardization and incomplete capture of data on the incidence and outcome of brain injury, with variability in the definition of TBI being partly to blame. Reports show changes in epidemiological patterns of TBI: the median age of individuals who experience TBI is increasing, and falls have now surpassed road traffic incidents as the leading cause of this injury. Despite claims to the contrary, no clear decrease in TBI-related mortality or improvement of overall outcome has been observed over the past two decades. In this Perspectives article, we discuss the strengths and limitations of epidemiological studies, address the variability in its definition, and highlight changing epidemiological patterns. Taken together, these analyses identify a great need for standardized epidemiological monitoring in TBI.
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Abstract New information about the basal ganglia and cerebellar connections with the cerebral cortex has prompted a reevaluation of the role of the basal ganglia in cognition. We know that the relation between the basal ganglia and the cerebral cortical region allows for connections organized into discrete circuits. Rather than serving as a means for widespread cortical areas to gain access to the motor system, these loops reciprocally interconnect a large and diverse set of cerebral cortical areas with the basal ganglia. The properties of neurons within the basal ganglia or cerebellar components of these circuits resemble the properties of neurons within the cortical areas subserved by these loops. For example, neuronal activity within the basal ganglia and cerebellar loops with motor areas of the cerebral cortex is highly correlated with parameters of movement, whereas neuronal activity within the basal ganglia and cerebellar loops with areas of the prefrontal cortex is more related to the aspects of cognitive function. Thus, individual loops appear to be involved in distinct behavioral functions. Studies of the basal ganglia and cerebellar pathology support this conclusion. Damage to the basal ganglia or cerebellar components of circuits with motor areas of the cortex leads to motor symptoms, whereas damage to the subcortical components of circuits with nonmotor areas of the cortex causes higher-order deficits. In this report, we review some of the new anatomic, physiologic, and behavioral findings that have contributed to a reappraisal of function concerning the basal ganglia and cerebellar loops with the cerebral cortex and apply it in clinical applications to obsessive-compulsive disorder, Tourette's syndrome, and attention-deficit/hyperactivity disorder as examples of how compromise at different points in the system may yield similar but different clinical results.
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The term persistent vegetative state (PVS) refers to the only circumstance in which an apparent dissociation of both components of consciousness is found, characterized by preservation of wakefulness with an apparent loss of awareness. Several authors have recently demonstrated by functional neuroimaging studies that a small subset of unresponsive "vegetative" patients may show unambiguous signs of consciousness and command following that is inaccessible to clinical examination at the bedside. The term "estado vegetativo" used in Spanish to describe the PVS syndrome by physicians came from the English-Spanish translation. The Spanish term "vegetativo" is related to unconscious vital functions, and "vegetal" is relative to plants. According to our experience, when a physician informs to patients' relatives that his/her family member's diagnosis is a "estado vegetativo", they understand the he/she is no more a human being, that there is no hope of recovery. The European Task Force on Disorders of Consciousness has recently proposed a new term, unresponsive wakefulness syndrome (UWS), to assist society in avoiding the depreciatory term vegetative state. Our group has embraced the use of the new term UWS and might suggest that we change our concept and use of the term MCS to minimally responsive wakefulness state (MRWS), or minimally aware wakefulness state (MAWS). Medical terms must be current and avoid any pejorative description of patients, which will promote our abilities to serve humankind and challenge neuroscientists to offer society new and realistic hopes for neurorehabilitation.
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Objective: To assess the autonomic nervous system (ANS) in coma by heart rate variability (HRV). Methods: Sixteen comatose patients and 22 normal subjects with comparable ages and genders were studied. Patients were classified in two subgroups according to the Glasgow Coma Scale (GCS). Time, frequency, and informational HRV domain indices were calculated. Results: A notable reduction of HRV was found in patients. Regarding the time domain indices, the triangular index, and the Delta_RRs, were significantly reduced in the subgroup with GCS=3. Absolute power for the whole frequency spectrum decreased whenever GCS scores were lower. A significant decrement was found for absolute power of the VLF and LF bands in the subgroup of GCS=3, and although it was lower for the HF band in these patients, those changes were not statistically significantly different. The LF/HF ratio and the Shannon´s entropy indices were significantly reduced in the subgroup with GCS=3. Our results are discussed regarding the progressive dysfunction the ANS networks when coma deepens. Conclusions: The HRV procedure is a powerful tool to assess the ANS in comatose patients. Significance: HRV is a minimally invasive, low-cost methodology, suitable for assessing the ANS in coma.
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Objective: To evaluate the role of dextromethorphan/quinidine (DM/Q; Nuedexta™) in the treatment of pseudobulbar affect (PBA).Data Sources: A literature search of MEDLINE/PubMed (January 1966-June 2013) was conducted using search terms pseudobulbar affect, pathological laughing and/or crying, emotional lability, dextromethorphan, and quinidine.Study Selection and Data Extraction: English language clinical trials and case reports evaluating the safety and efficacy of DM/Q in PBA were included for review. Bibliographies of all relevant articles were reviewed for additional citations.Data Synthesis: PBA, a poorly understood disorder, is characterized by involuntary crying and/or laughing. In the past, antidepressants and antiepileptics have been used off-label with mixed results. Four clinical trials have evaluated the use of DM/Q for the treatment of PBA. Although the therapeutic outcomes with DM/Q have been positive, interpretation of the published evidence is limited by small sample size and short treatment duration.Conclusions: Based on the data available, DM/Q may be a viable, short-term treatment alternative for PBA. Long-term safety and efficacy data are lacking.
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Although still considered experimental by some, computerized posturography is becoming more and more the standard assessment of balance and neuromuscular control mechanisms while standing. However, there is no consensus as to the data acquisition parameters to be used. Depending on which posturography school one belongs to, acquisition frequencies vary from a few Hz all the way to 1 kHz, and little attention is usually given to the post-sampling filter cut-off frequency (implemented either in the hardware or in the software used to acquire the data), often without realizing the consequences such choices will have on the results. But the sampling and the filter cut-off frequencies are particularly important when dealing with spectral analysis or when secondary measurements such as the center of pressure coordinates, sway path length, velocity or acceleration are calculated from the measured forces and moments. In this paper, frequency content of vertical ground reaction force and center of pressure path coordinates excursion were determined for 946 subjects of both genders, with various age, height, body type, health status and nationality. The results of this spectral analysis made it possible to draw some general conclusions as to what should be a proper acquisition frequency for posturographic data.
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Problems with balance and dizziness are one of the most common complaints of individuals who have experienced a brain injury and are reported in up to 90% of cases. Despite the ubiquity of vestibular disturbance in this population, there remains a dearth of research on the interaction between physiological and cognitive systems responsible for maintaining balance. The purpose of this article is to review studies on the interaction of physiological and cognitive processes required to maintain balance that may aide assessment and recovery of balance disturbance in patients with brain injury. This article provides a review of research on the role of higher order cognitive processes in maintaining balance and rational for further inclusion of neurocognitive measures in the assessment of vestibular disturbance. Greater inclusion of neurocognitive measures in assessment of vestibular disturbance provides a method of assessment containing increased ecological validity compared to traditional assessments, better prepares patients for discharge, and may reduce the incidence of future injury.
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All degrees of traumatic brain injury (TBI) are associated with balance dysfunction and/or dizziness. The clinician assessing and managing patients with TBI should become familiar with vestibular and non-vestibular causes of dizziness and imbalance, and be able to perform screening tests to determine when referral to a vestibular specialist is warranted. This chapter outlines the clinical pathways to be followed in history-taking, physical examination, and assessment. Dizziness, vertigo, balance dysfunction and gait ataxia can have their origin in the vestibular system, elsewhere, or be multifactorial. The complex anatomy and physiology of the balance canals, otolithic organs, and vestibular nerves peripherally, and the vestibular nuclei centrally, as well as the neural connections between vestibular, oculomotor, and proprioceptive systems will be covered in clinically pertinent detail. A majority of diagnosis of dizziness/vertigo can be made after a proper history has been obtained. This can be challenging in all dizzy patients, and more so in the TBI patient in whom memory and recall may be impaired. The reader will learn how to use tools such as dizziness questionnaires as well as targeted history taking to elicit the information. Similarly, the addition of a programmatic, targeted physical examination of the dizzy patient will allow the clinician to fine-tune the diagnosis between peripheral and central causes. Once history and examination have narrowed the diagnostic possibilities, appropriate testing - in the vestibular laboratory and radiologic testing - is indicated. The reader will learn when these tests should be considered, and what the findings will show. Treatment can then be targeted for maximal outcome. Managing TBI is challenging; the addition of dizziness or balance complaints in these individuals makes it even more so. This paper seeks to provide a useful roadmap clinical pathway for assessment of these patients with appropriate and timely referral for treatment.
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Pseudobulbar affect (PBA) manifests in a variety of neurologic illnesses suggesting a heterogeneous pathophysiology with common underpinnings. We report successful treatment of PBA with a selective serotonin reuptake inhibitor (SSRI) in a 54-year-old woman following progressive multifocal leukoencephalopathy (PML). In light of recent focus on dextromethorphan/quinidine (DM/Q) for the treatment of PBA, the clinician is reminded of the effectiveness of SSRIs.
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Vestibular complaints are the most frequent sequelae of mTBI. Vestibular physical therapy has been established as the most important treatment modality for this group of patients. Nevertheless there is little work objectively documenting the impact of vestibular physical therapy on this group of patients. Studies have been completed in the past examining clinical measures like the GCS on overall recovery pattern after TBI. But outcomes measures specifically aimed at examining the adequacy of vestibular tests to track vestibular recoveryhave remained lacking. Scherer and Schubert reinforced the need for best practice vestibular assessment for formulation of appropriate vestibular physical therapy treatment strategies. Now the application of vestibular testing and rehabilitation in this patient population is needed to provide information on objective outcome measures. Vestibular physical therapy is most effective when applied in a customized fashion. While we and others have developed vestibular physical therapy procedures that are applied in best practices for mTBI vestibular patients, these therapies must be customized for the patient entry level of function and expectation level of recovery. Knowledge of the patient's disability and diagnosis is critical to build the foundation for return to activity, work, or sport.