Therapeutic educational workshops for caregivers of patients with severe acquired brain injury

Abstract

Severe acquired brain injury (sABI) leads to a wide range of functional limitations in cognitive, moto and behavioural abilities. These changes impact the patient's family in terms of the feeling of emotional and physical health, social life and financial condition. Caregivers are often intensely involved in the patient's management exposing them to negative effects of caregiving including stress, mood disorders and decreased quality of life. Implementing forms of active involvement of caregivers in the rehabilitative program could be useful. Thus, in the present study, therapeutic educational workshops (TEWs) for caregivers during the post-acute intensive hospitalization were organized during the post-acute intensive hospitalization of patients with sABI. The caregivers were asked to participate in the workshops to actively involve them in the patient's care and neurorehabilitation program. Each workshop session provided indications regarding the management of the patient with aphasia, neglect, behavioural and swallowing disorders. A questionnaire of 22 items has been designed in order to represent possible indicators of usefulness and effectiveness of the TEWs. The primary aim of this study was to develop a reliable and valid questionnaire able to assess the caregivers' satisfaction with the modalities of carrying out the TEW as a novel activity during the post-acute hospitalization of patients with sABI. The second aim was to assess the caregivers' satisfaction with the utility of the TEW as a tool to enhance their skills in the management of patients' disabilities. 100 caregivers of patients with sABI who attended at least one TEW session and completed the questionnaire were included in the analysis. In conclusion the administered questionnaire has proven to be a valid and reliable tool to evaluate sABI caregivers' satisfaction with TEW. Moreover, caregivers were satisfied with the organization of the TEW and with their usefulness in the management of the patients with sABI.

Is the patient able to watch TV or read the newspaper? A functional semi-structured scale to observe Hemineglect symptoms in Activities of Daily Living (H-ADL)

We developed a functional semi-structured scale to observe Hemineglect symptoms in Activities of Daily Living (H-ADL). The scale could assist clinicians in assessing rehabilitation priorities aimed at correcting any persisting errors or omissions. In addition, the scale could also be used by caregivers to observe patients' progress and improve their participation. Two groups of right brain-damaged patients (25 with hemineglect; 27 without hemineglect) were tested twice: at admission and before discharge from hospital. A control group of healthy individuals matched to patients for age and education and patients' caregivers also participated. Two raters (A; B), experts in neuropsychology, observed patients and healthy individuals using the H-ADL. We found that the H-ADL final scores correlated with the standard hemineglect tests. The three groups differed in performance and differences also emerged between the first and the second assessment, suggesting an improvement due to the remission of hemineglect as a consequence of the treatment. Raters A and B did not differ in their observations, but there were some discrepancies with caregivers' observations. Therefore, although caregivers could help clinicians in detecting persistent hemineglect behaviour, the assessment should be performed by experts in neuropsychology.

Retinotopic modulation of space misrepresentation in unilateral neglect: evidence from quadrantanopia

A patient with right sided brain damage suffered contralesional neglect, inferior quadrantanopia (with 0 degrees sparing in the left eye and 13 degrees sparing in the right), and a visual field restriction (to 15 degrees ) in the upper contralesional quadrant of the left eye. In binocular vision, the patient showed underestimation of the horizontal size of contralesional line segments unless cued to localise their end points. When asked to reproduce, in monocular vision, 10 degrees and 20 degrees distances between two attentionally cued end points lying on the frontal vertical plane, the patient showed relative contralesional overextension and ipselesional underextension along the directions falling within the blind sectors of the neglected space. No asymmetry was present along the directions falling within the seeing sectors of the same space. These findings suggest precise retinotopic modulation of space misrepresentation in unilateral neglect.

Dissociation between position sense and visual-spatial components of hemineglect through a specific rehabilitation treatment

Current evidence suggests an association between contralesional extra-personal hemineglect, and deficits of arm position sense in patients with damage to the right cerebral hemisphere. A unitary deficit may produce both disorders, or this association may reflect the anatomical contiguity of relevant brain structures. A rehabilitation treatment, devised for visual-spatial hemineglect, was used to investigate these hypotheses in 8 patients with damage to the right cerebral hemisphere. The treatment improved hemineglect, but not the position sense deficit. The severity of the latter was however transiently reduced by optokinetic stimulation, with effects similar to those found in visual-spatial hemineglect. These effects of rehabilitation suggest that extra-personal hemineglect and the neglect-related component of the position sense disorder of the left forearm are independent, though frequently associated, deficits. Implications for the design of rehabilitation programs are discussed.

Facilitatory effect of neglect rehabilitation on the recovery of left hemiplegic stroke patients: a cross-over study

A study of the effect of specific training for visual neglect on the recovery of motor and functional impairment in stroke patients is reported. Two groups of right hemisphere stroke patients with hemispatial neglect and one group without neglect were assessed by means of three functional and neurological scales (Rivermead Mobility Index, Barthel Index, Canadian Neurological Scale). Three evaluations were made at 0, 2 and 4 months from the beginning of physical rehabilitation. During the first 2 months of physical rehabilitation one of the two groups of neglect patients was randomly assigned to specific training for neglect, and the second group to a general cognitive intervention; during the final 2 months of rehabilitation the types of training were switched in the two groups. The non-neglect patients improved steadily during physical rehabilitation. In contrast, the functional recovery of the two neglect groups was time-locked to the period of the specific training for neglect. At the time of admission, the two neglect groups performed at the same level; after 2 months of rehabilitation, the group with neglect training showed higher functional recovery than the group with only general cognitive intervention. When the latter group received neglect training, there was no longer any difference between the two neglect groups. This pattern was present for both of the functional scales used but not for the neurological scale. Motor and functional recovery of stroke patients with neglect seems to be significantly improved by the simultaneous presence of a treatment specifically focused on neglect.

Optokinetic stimulation affects both vertical and horizontal deficits of position sense in unilateral neglect

The effects of optokinetic stimulation on the disorders of position sense in the horizontal and vertical planes were assessed in 24 patients with unilateral cerebral lesions (eight right brain-damaged patients with visuo-spatial hemineglect, eight right brain-damaged patients without neglect, eight left brain-damaged patients without neglect). In neglect patients, the position sense disorder was more severe, and affected by optokinetic stimulation in a direction-specific fashion. In both the horizontal and the vertical plane, and in both arms, stimulation with a direction of the movement contralateral to the side of the lesion improved the disorder, whereas stimulation with an ipsilateral direction worsened the deficit. The suggestion is made that in patients with neglect the disorder of position sense is produced, at least in part, by an ipsilateral distortion of an egocentric co-ordinate system, comprising both the horizontal and the vertical dimension, which may be affected by direction-specific optokinetic stimuli.

Effectiveness of neglect rehabilitation in a randomized group study

The effectiveness of neglect rehabilitation training has been studied in two randomly selected groups of right brain-damaged patients. All patients proved heminattentive on a standard battery 2 months or more after the CVA. One group received 2 months of treatment immediately after admission to a clinic, and the other group received only general cognitive stimulation for the same amount of time. At the end of this period a comparison showed significant improvement in the first group, based on a standard test battery and a functional scale. The second group was then given rehabilitation training for neglect for the same amount of time and obtained similar improvement. It is concluded that the rehabilitation program produces significant results, which generalize to situations similar to those of everyday life. The importance of the duration of training on the generalization of learning is briefly discussed with reference to previous negative reports in the literature.