Whilst many investigators concede that traumatic brain injury (TBI) without loss of consciousness (LOC) can occur, the number of times that this phenomena is reported in the literature is small. This case report presents an instance of TBI without LOC as supported by the observation of slowed processing speed, anosmia and a marked post-traumatic dysexecutive syndrome featuring moderately severe disinhibition. The case is discussed with a view to determining the mechanics of the blow necessary to both damage the cerebral substance yet maintain consciousness intact.

In 1991 Dr Kevin Walsh, the founding President of ASSBI, presented an invited address entitled “Some gnomes worth knowing” in which he discussed examples of common errors and difficulties in neuropsychological test interpretation in the form of “gnomes” or aphorisms from prominent clinicians. His paper was aimed at demonstrating “the need for improvement in the education of all psychologists who are likely to be faced with essentially neuropsychological problems”. The current paper will examine the extent to which such improvement has occurred over the past eight years and will consider directions for the future. The major areas of concern outlined by Dr Walsh will be reviewed in terms of current clinical practice. Additional areas of controversy and concern which have emerged more recently, such as the assessment of mild head injury, the assessment of malingering and the impact of neurochemical changes in certain psychiatric conditions, will also be considered. The importance of considering the client in a more holistic manner, which takes into account a range of issues that may impact upon test scores, is emphasised. It is hoped that this presentation will assist in formulating more clearly the challenges facing all those involved in research, assessment and treatment of brain disorders as we approach a new millennium.

Following severe traumatic brain injury, difficulty with behavioural adjustment and community reintegration is common. A potential contributor to this difficulty is a sense of personal identity that is inconsistent with the restrictions on activity and need for effortful compensation imposed by persistent impairment. We summarise an information processing framework within which the impact of schematic mental models of self is explained and present intervention procedures designed to help individuals with traumatic brain injury reconstruct an organised and positive sense of personal identity. We conclude the paper with three instructive case illustrations.

In the early stages of recovery after a traumatic brain injury, patients usually experience a period of posttraumatic amnesia (PTA) in which they are confused, amnesic for ongoing events, and frequently behaviourally agitated. Although a variety of procedures and instruments are available to measure the duration of PTA, their applications in clinical practice are far from ideal. This review paper describes retrospective and prospective measures of PTA and critically examines variations in item content and scoring procedures. In particular, methods currently available to measure the amnesia component of PTA are especially problematic. The limitations of PTA scales give rise to a number of difficulties that impact upon clinical practice. These include determining precisely when a patient has emerged from PTA, and distinguishing between patients in PTA and those with chronic amnesia. It is concluded that there is a need to revisit basic constructs comprising PTA, and develop an instrument with greater specificity. More focus should be placed on examining the confusional component of PTA, and validity of PTA tests would be improved by measuring attention and behaviour, in addition to orientation and memory.

Children with acquired brain injury (ABI) experience deficits in attentional skills such as, sustained attention, distractability and impulsivity, which have the potential to influence all aspects of their functioning. The use of central nervous system (CNS) stimulants is gaining increasing popularity in adult ABI literature. CNS stimulants have been successfully utilised in the management of attentional problems in attention deficit-hyperactivity disorder and are believed to have their therapeutic effect by modulating neurotransmitter function in the neocortex, an area of the brain implicated in the neurobehavioural sequelae of ABI. Research into the use of CNS stimulants in paediatric ABI reports contradictory findings. We present the case of LI a 7-year-old boy with a history of ABI who underwent a trial of stimulant medication for management of attentional deficits. The case is discussed with regard to the efficacy of the pharmacological intervention and the design of objective protocols for stimulant trials.

Evidence-based practice involves the use of evidence from systematic reviews and randomised controlled trials. The extent of this evidence in neurological physiotherapy has not previously been surveyed. The aim of this study was to describe the quantity and quality of randomised controlled trials, and the quantity and scope of systematic reviews relevant to neurological physiotherapy. PEDro (the Physiotherapy Evidence Database) was searched for trials and reviews relevant to neurological physiotherapy (adult and paediatric). The quality and quantity of trials were analysed, and the topics and conclusions of reviews were synthesised. The search revealed a total of 265 records, consisting of 238 randomised controlled trials and 27 systematic reviews. Since the first trial was published in 1958, the number of trials has expanded exponentially. Fifty-four percent of trials were categorised as being of moderate to high quality, rating five or more out of ten. The first review was published in 1991. Many of the reviews have been unable to reach firm conclusions due to the paucity of available trials. The results show that there is a substantial body of evidence relevant to neurological physiotherapy. However, there remains scope for improvements in the quality of the conduct and reporting of clinical trials. There is an urgent need for more randomised controlled trials and systematic reviews.

During the process of community integration, individuals with acquired brain injury may experience difficulties in all areas of occupational performance including self-care, home management, community access, leisure, social activities and vocational pursuits. Community based rehabilitation services provide opportunities to minimise such difficulties by working with clients as they engage in meaningful real-life context-based occupations. The therapeutic use of occupation is at the core of occupational therapy practice. We reflect on the nature and principles of occupation and highlight particular benefits for facilitating community integration after brain injury. This is illustrated using the example of executive dysfunction. Several challenges for the occupational therapy profession arise from the shift in focus from hospital to community based rehabilitation, and the need for further research on community integration after brain injury from an occupational perspective is recognised.

This article reviews current literature on social support and friendship, loneliness and social isolation, and discusses these in the context of disability and specifically acquired brain injury. The examination provides a backdrop for considering interventions which aim to promote or regenerate friendships in the lives of people with this injury. The social consequences for individuals who have sustained an acquired brain injury have been well documented and are briefly reviewed. An understanding of the social support and friendship literature, reviewed in this article, is helpful for practitioners in designing interventions in the lives of this group of people, whose limited friendship and social support systems compromise quality of life and inclusion in the community. The article describes interventions that have been attempted to facilitate network building and friendship development for vulnerable or disadvantaged people in a wide range of contexts. The role of informal support systems is also discussed. A critique of these interventions is also presented and the conclusion reached is that while such models are not perfect and are often not rigorously evaluated, it is critical to provide assistance in order to achieve genuine social inclusion of people with acquired brain injury. It is their human right.

This paper deals with research which makes links between developmental problems such as language-learning disorders, attentional disorders, and behaviour disturbance on the one hand, and risk for misuse of alcohol and other drugs (AOD) in adolescence on the other. Poor academic performance is frequently cited as a risk for adolescent AOD misuse, however few workers have critically examined the role of linguistically-based academic sub-skills (e.g., oral and written language competence; strong social skills) which normally contribute to academic success, and hence operate as protective factors with respect to risk for AOD misuse. Studies which specifically address language skills and their association with risk for AOD misuse are reviewed, as are investigations which deal with patterns of comorbidity which are typically evident in clinical populations. Particular emphasis is placed on comorbidities between language-learning difficulties on the one hand, and behavioural or attentional disorders, on the other. It is argued that more explicitly investigating and intervening at the level of core language/social skill competencies might serve to strengthen protective factors in vulnerable groups. It is also noted that comorbid problems need to be considered as important covariates in studies of language disordered children and adolescents, rather than being treated as exclusionary criteria.