Objective: To summarise the effect of upper limb rehabilitation interventions on motor function in adults with traumatic brain injury. Data sources: Databases were last searched on August 2, 2008. Sources included the Cochrane Central Register of Controlled Trials (CENTRAL); Cochrane Database of Systematic Reviews, the Database of Effectiveness Reviews; MEDLINE, EMBASE, CINAHL, Physiotherapy Evidence Database (PEDro), Occupational Therapy Systematic Evaluation of Evidence database (OTseeker); Google Scholar; and reference lists of included studies. Review methods: Two reviewers determined whether retrieved abstracts met the inclusion criteria: systematic reviews and randomised controlled trials (RCTs); English language; adult participants; ≥ 50% of study participants with a brain injury; interventions designed to improve upper limb motor function. Included papers were appraised for: study design, participants, therapy approach, therapy protocol (indications, contra-indications, intensity and duration), safety and adverse events, and outcomes. The methodological quality of RCTs was rated using the PEDro scale (1–10 highest). Methodology of systematic reviews was rated using the QUOROM criteria. Results: Of the 333 references identified, six were appraised: three systematic reviews and three RCTs. Methodological quality was high for two RCTs, and moderate for one, based on the PEDro scale score. Interventions included upper limb casting, electrical stimulation, and coordination training using meal preparation tasks (making a sandwich and hot drink). In the latter trial, practice of functional kitchen tasks improved fine motor coordination speed on one of four Jebsen-Taylor hand function subtests by 9.38 seconds (95% CI, 1.1 to 17.7). Remaining trials reported non-significant effects for hand function. Small sample sizes and limited reporting of results reduce the interpretability of two RCTs. Conclusion: No conclusive evidence was found on which to base upper limb motor rehabilitation after brain injury, however, lack of evidence does not equate to evidence of no effect.

The aim of the study was to compare beliefs and experiences of traumatic brain injury (TBI) in patients with TBI from the dominant English-speaking culture in Australia versus those from minority culturally and linguistically diverse (CALD) backgrounds and examine the relative influence of beliefs, acculturation, along with demographic and injury-related variables on outcome. The primary measures included the Illness Perception Questionnaire-Revised (IPQ-R), and the Craig Handicap Assessment and Reporting Technique (CHART). Participants were 70 individuals with mild to severe TBI, including 38 of English-speaking background (ESB) and 32 from CALD backgrounds. Although similar to the ESB participants in education, preinjury employment status, injury severity and experience of TBI, the CALD participants differed significantly from ESB participants on acculturation variables. CALD participants also experienced greater negative emotions and were less likely to have internal locus of control causal beliefs than ESB participants. Regression analyses indicated that describing one's value system as other than Australian, poorer understanding of TBI and greater negative emotional reactions, along with fewer years of education were associated with poorer outcomes on the CHART. Thus, in treating patients from different cultural backgrounds it is important for health professionals to understand beliefs about and responses to TBI, as they could potentially impact on coping, emotional adjustment and long-term outcome.

Objective: To describe the development of a functional communication assessment. A secondary aim is to illustrate a process for identifying functional communication outcomes in clients with traumatic brain injury (TBI). The TBI Index for Social and Vocational Communication Outcomes (SAVCO) is designed to identify limitations to everyday communication activities that may present following TBI. It was constructed by anchoring communication activities derived from studies within New Zealand into an internationally recognised theoretical construct, the International Classification of Functioning, Disability and Health (ICF). Four key principles: authenticity of the items, attention to context, collaboration and transparency, underpin the assessment. Main outcomes: The article describes the process of developing a TBI measure that is authentic to an intended population. It provides a preliminary description of the SAVCO, its different constructs and the rationale for their inclusion. The SAVCO is an assessment that highlights everyday activities that are relevant targets for intervention for the individual. The client's performance on the identified activities is explored according to the efficiency and manner of executing the activity. The scope and level of the activity are also determined. Conclusions: The development of the SAVCO illustrates a process for identifying relevant and important functional communication activity items and promotes the use of the ICF framework and rating scales. The preliminary findings suggest that the SAVCO has clinical relevance providing speech–language therapists with a functional communication assessment that leads to the identification and measurement of client-centred therapy outcomes.

Assessment of posttraumatic amnesia (PTA) in young children remains problematic. This article details a version of the Westmead PTA Scale, which was adapted for use with children aged 4 and 5 years, and an evaluation of this scale with typically developing children. The Westmead PTA Scale for Children (WPTAS-C) comprises 2 orientation and 4 memory questions, including 2 items involving remembering pictures of familiar objects. Participants included 55 preschool and kindergarten children aged 4 and 5 years. The scale was administered for 4 consecutive days. Ninety-three per cent of the children achieved a score of 6 out 6 for the final 3 days of the 4-day test period. It is concluded that the WPTAS-C is an appropriate measure of orientation and continuous memory in 4- and 5-year-old typically developing children. Validation of the scale in clinical populations is recommended.

The need for stroke rehabilitation will lessen if stroke incidence declines and acute stroke medical and surgical treatment improves. The burden of stroke will also lessen as effective rehabilitation services (stroke rehabilitation units) and interventions are widely implemented. Despite the considerable amount of evidence available, implementation has been slow. Improvement in stroke rehabilitation will require continued professional advocacy, supported by local and national audit and future focused research.

Neurological patients can be entirely unaware of their disease; this phenomenon is called anosognosia and it has been shown in different sensory-motor and cognitive domains. Lack of awareness has been investigated in Alzheimer's disease (AD) and within different domains of it. In the present article we review the literature on anosognosia for AD that had been indexed on the Medline database until the end of 2004. Historical introduction to the subject is followed by a brief description of the anatomy and clinical characteristics of AD. An analysis of a number of studies that focus on the relationship between anosognosia and AD then follows. This review shows that anosognosia is typical in AD, compared with other types of dementia, and it is a distinctive feature in the most severe cases and particularly in the beginning phases of illness. From an anatomical point of view, anosognosia seems to be strictly connected to frontal lobe areas; in fact, patients with anosognosia and AD show a reduction of cerebral haematic flow in the frontal regions, as well as deficits of executive functions and extrapyramidal signs. Interestingly, co-occurring depression could be interpreted as an adaptive behavior to counter the effects of perceived loss of cognitive abilities. Finally, self-awareness in AD could have some common mechanisms with auto-monitoring in schizophrenia.

Skilled action is the end-product of learning processes that can improve several aspects of motor control such as strategic movement organisation, perceptual–motor associations, or muscle commands for basic components of sequentially evolving, complex movements. Experimental studies in healthy participants using functional imaging and transcranial magnetic stimulation have identified separable processes that form cortical motor representations and that assist this formation of representations. These processes capitalise on use-dependent plasticity and changes in cortical excitability before and after practice. In terms of neural circuits, motor learning manifests measurably via structures that support transient phenomena, such as attentive error monitoring, or through continued activation of brain structures that support control processes still adapting. Specifically, movement guidance engages the dorsal premotor and parietal cortex along the intraparietal sulcus in addition to the supplementary motor area and the anterior cerebellum. Movement conception based on explicit experience of the movement task involves the inferior premotor cortex. Evidence in patients recovering from brain lesions such as stroke, suggests that similar principles hold for neurorehabilitation as well. The challenging issue is to what degree altered motor strategies afford improvement in function through relearning and neural plasticity.

The long-term outcome of persons with impaired consciousness after brain injury remains relatively unclear. The first 12 months post ictus are widely reported as the period of greatest change, with an estimated 20% of persons with traumatic brain injury recovering consciousness. However, beyond 12 months post traumatic and 6 months post-nontraumatic injury the chances of further recovery are thought to diminish significantly. The aim of this study was to investigate the behavioural and psychosocial outcome of 12 patients with impaired consciousness 2 years post ictus. At the time of recruitment five of these patients met the diagnostic criteria defining the vegetative state and seven of these patients met the diagnostic criteria defining the minimally conscious state. Patients were assessed using the Wessex Head Injury Matrix at recruitment and again at least 2 years after initial contact. Functional and psychosocial outcome were also explored. Most patients showed some improvements to their behavioural portfolio, but all were still very dependent physically and all required a high level of support in their activities of daily living. None of the patients had emerged from their original condition, despite exhibiting larger behavioural portfolios. The implications of these findings for the management of patients in low awareness states are discussed.

This article is concerned with patients in coma, the vegetative, or minimally conscious states. Studies addressing the issue of assessment and management of these patients are described. These include (a) the development of an assessment tool (Wessex Head Injury Matrix, WHIM); (b) use of the WHIM to assess the effects of posture on arousal, showing that some 75% of patients show more behaviours when assessed while they are in a standing frame than when supine; (c) a comparison of the WHIM with the Glasgow Coma Scale, demonstrating that the WHIM is more sensitive than the GCS for measuring the behavioural repertoire of people in states of reduced consciousness; (d) a discussion of situations when neuro-imaging techniques are required to assess residual functioning; and (e) the long term outcome of one of the first vegetative patients to be scanned with Positron Emission Tomography (PET). We conclude with a discussion about neuropsychology and patients in states of impaired consciousness.

The current study was designed to determine whether the Social Performance Survey Schedule (SPSS; Lowe & Cautela, 1978) is a useful measure of social skills in people with traumatic brain injuries (TBI). Forty-nine adults with TBI were compared on the SPSS to 190 adults without injuries. The validity of the SPSS was also investigated in relation to another measure of social performance, the first scale of the Katz Adjustment Scale (KAS-R1; Katz & Lyerly, 1963) and a broad measure of social function (the SPRS; Tate, Hodgkinson, Veerabangsa, & Maggiotto, 1999). Individuals with TBI had significantly lower scores on the positive scale of the SPSS than nonbrain-injured individuals. They did not have lower scores on the SPSS negative scale relative to the normative sample. Significant correlations with the KAS-R1 and SPRS provided evidence for the construct and criterion validity of SPSS within this population. In conclusion, this study suggests that where an appropriate normative sample is used, the positive subscale of the SPSS is a sound measure for detecting the extent and nature of deficits in prosocial behaviour seen in TBI, but raises the question as to how we define negative behaviours in the 21st century on scales such as the SPSS.

Impaired somatosensory processing could contribute to handgrip limitation following stroke. The aim of this study was to examine the association between somatosensory function measured by psychophysical tests and clinical measures of handgrip limitation poststroke. Forty-five people with stroke who could perform a pinch grip task were recruited from rehabilitation settings. Ability to discriminate surface friction, and to match object weight were quantified using psychophysical methods. Handgrip limitation was measured using items of the Motor Assessment Scale, Jebsen Taylor Hand Function Test and the Hand Function Survey. Impaired discrimination of surface friction was moderately to weakly associated with handgrip limitation (rs = .36 to .55). In contrast, an association between degree of impairment in matching weight and handgrip limitation poststroke was not observed (rs < .24). The findings suggest that processing of tactile cues arising between the object and skin when training handgrip ability may be beneficial for people with stroke.

The International Classification of Functioning, Disability and Health (ICF) is a taxonomy that classifies health states and health conditions. It is a complex and detailed taxonomy, with 1,424 categories, covering body structures and functions, activities and participation, and environmental factors. The complexity and detail, however, can serve as a barrier in its everyday application. A number of strategies have been developed to facilitate use of the ICF in clinical and research practice, including the development of ‘core sets’. In this article, we present another method which will assist both the newcomer and those more familiar with the ICF. Along with a description of the ICF structure and contents, the article presents a graphical representation of ‘ICF trees’ as a vehicle to more readily grasp the detail of the ICF structure and contents and facilitate its use in the area of acquired brain impairment.

Background and purpose: Adherence to medication is fundamental to optimal health recovery yet compliance to medication rates are lower than 50% in most studies. This study aimed to investigate the correlates of adherence in stroke patients. Method: Twenty-six stroke patients and 29 amputee patients who had completed a rehabilitation program at Melbourne Rehabilitation Centre were investigated. Medical adherence was determined from computed adherence metrics based on pill counts and subjective reports of patient knowledge of medication use. Model components that were believed to contribute to poor adherence, included emotional and cognitive dysfunction, beliefs about medication, and social support. These factors were assessed by patient and partner self-rating questionnaires. Results: Stroke patients showed a lower level of adherence compared to amputee patients. Cognitive and emotional dysfunction, beliefs about medication, and the level of care were significantly associated with low adherence to medicine regimes in stroke patients. Level of cognitive impairment and emotional impairment were significantly associated with low adherence to medicines in amputee patients. Emotional dysfunction was the best predictor of poor adherence in both patient groups. Conclusion: The findings are in keeping with past adherence studies with other patient groups and support the position that emotional, cognitive, and social factors are important factors in adherence. The specific nonadherence profile for this brain-damaged group is modeled and the application for outpatients following rehabilitation is discussed.

The application of neuroscience advances to brain injury is addressed in the context of our studies of the role of the corpus callosum in the interhemispheric transfer of auditory and tactile information. The outcome of these studies, which were conducted over a period of 30 years in normal individuals as well as those with congenital and acquired lesions of the corpus callosum, have since been confirmed and extended by modern brain imaging techniques. These techniques nevertheless continue to rely on the use of sensitive, specific, valid and reliable behavioural testing paradigms.

The proportion of disabled stroke survivors is increasing. These people may experience loss of sensation that negatively impacts on performance and participation in daily activities. The value of adopting active approaches to rehabilitation is growing; however, high costs and demand over an extended period of time impose limits on therapist-based application. Informal carers and family members are a potential, low-cost resource for expanding the scope of rehabilitation across environments and over extended time periods. We systematically developed and established the effectiveness of an approach to retraining lost sensation and function in the hand that has positive outcomes in relation to the ability to feel everyday textures and objects and use the hand in daily tasks. The purpose of this study was to investigate whether family members, as surrogate therapists, are able to effectively conduct the sensory training program in home environments. Three single-case quasi-experiments were conducted in which stroke survivors' spouses implemented the training program across touch or limb position sensations. We found positive treatment effects in all cases. These findings indicate that selected surrogate therapists (spouses) can successfully implement a program of sensory retraining when provided 2 to 3 hours of training and supervision by a qualified therapist.

This article provides a review of the development and clinical practice of the ABI Behaviour Consultancy (the ‘Consultancy’), a specialist clinical service that provides outreach behaviour management support across the state of Victoria, Australia, to people with acquired brain injury (ABI) and their social network (i.e., family members, friends, support workers, and therapists). The Consultancy is a small, unique service that has developed ways of providing behaviour management strategies in community settings, despite the difficulties presented by changing and uncontrolled environments. The aim of this article is to provide a detailed account of this service. Information from the first 7 years of full operation, 1998 to 2004, is presented, during which a small number of psychologists saw more than 800 clients. A detailed description is given of behaviours referred and associated risks, assessment procedures, intervention approaches, and research activity. A variety of key service aspects are detailed, including the qualifications required of specialised staff, the service funding levels, and funding and service issues. These detailed accounts of service delivery are placed in the context of several major themes: specialist versus generalist services, the deployment of targeted interventions throughout the lifespan of a brain-injured individual, the role of specialist behaviour management services in the continuum of brain-injury support services, and broader equity issues.