If performance-based extrinsic monetary reward is added to a task intrinsically motivated to perform, the intrinsic motivation drops(undermining effect). While a subject was performing a task based on intrinsicmotivation, the lateral prefrontal cortex and the striatum responded to the task-start cue and positive feedback, respectively, without extrinsic monetary reward. However, the intrinsic motivation is once decreased by the underminig effect, neither the lateral prefrontal responses to the task-start cue nor the striatal responses to the positive feedback appeared without extrinsic monetary reward. Subjects prefer choosing a tool for a task by herself/himself(self-determined choice condition)to being chosen by someone else(forced-choice condition), and the performance also reflects the preference. Whereas the ventromedial prefrontal response to the failure feedback was suppressed under forced-choice condition, the response to failure feedback was hold at the similar level to the positive feedback under self-determined choice condition. These findings suggest that the lateral and ventromedial prefrontal cortices as well as the striatum are involved in intrinsic motivation and its variation.
Symposium : Apathy and its therapeutic approaches in rehabilitation
Apathy is defined as a deficiency in overt behavioral, emotional and/or cognitive components of goa-by Marin and as the quantitative reduction of voluntary, goal-directed behaviors by Levy and Dubois. The underlying mechanisms responsible for apathy can be divided into three subtypes: emotional-affective processing, cognitive processing and auto-activation processing. Apathy is diagnosed based on clinical signs and symptoms, and the Yaruki Score, the Japanese version of the Apathy Scale developed by Starkstein, the Neuropsychiatric Inventory and the Clinical Assessment for Spontaneity, if necessary, should be used to evaluate the features and severity of this condition. Furthermore, the brain lesions responsible for apathy should be identified using magnetic resonance imaging and/or brain receptor scintigraphy. Pharmacological treatments for apathy include the administration of dopaminergic and noradrenergic agents in patients with stroke, traumatic brain injury or Parkinsonʼs disease and cholinesterase inhibitors in those with dementia. Non-pharmacological treatments consist of external cueing, the use of checklists, cognitive training, interviewing and external compensation, as well as music therapy, although the efficacy of these treatments has not yet been established. Further studies on the effects of training in patients with apathy should be performed taking into consideration the causes, underlying brain lesions, types, severity and progression of apathy.
It is known that subsequent to a stroke, depression(PSD)and apathy are manifested, but they are both sometimes confused, and even during rehabilitative care, are sometimes inappropriately handled. As such, we have studied the frequency of PSD and apathy during the convalescence stage, and the effects on func tional outcomes of administering SSRI and performing rehabilitation, and we discuss appropriate handling of PSD and apathy in the convalescent rehabilitation ward. Stroke patients in the convalescent rehabilitation ward underwent screening tests and psychological in terviews, and patients diagnosed with PSD were organized into a paroxetine administration group (paroxe tine group) and a nicergoline administration group (control group) , rehabilitation was conducted and the degree of severity of depression, walking ability and ADL were assessed. The frequency of PSD and apathy were 13.8％ and 30.6％, and at the time the drug administration was completed, the paroxetine group showed greater improvement in depression compared to the control group, but there was no difference in walking ability and ADL. It is possible that in the convalescent rehabilitation ward, if PSD is diagnosed, drug therapy using SSRI and conducting rehabilitation may result in an improvement in depression and a reduction in the psychological burden. For apathy, instruction and guidance based on the treatment plan during hospitalization, and post-discharge, the use of welfare services and outpatient service to maintain the amount of activity are ef fective.
Apathy following brain injury often leads to worse outcomes. In this article, the outcome of apathy and factorial analysis for improvement and worsening of apathy were investigated using 115 patients who were hospitalized in neuropsychiatric unit due to severe psychiatric symptoms after brain injury. Apathy was gradually improved, but at an extremely slow speed. Worsening of apathy was considered to be caused by physical illness, while improvement of apathy by unrestricted setting such as release from physical restrain as well as intensive rehabilitation. This study suggests that controlling physical illness and frame setting for rehabilitation play a critical role for approaches to apathy.
Workshop : Music therapy effects on persons with aphasia and dementia
Aphasic and demented patients have difficulties on verbal communication. Those difficulties cause further difficulties on building relationship with family or physiotherapists. Based on the 20 year music experiences, this study aimed to show positive effects of music therapy on aphasicʼs communication problems.
Background and Purpose The influence of standing position on tests for unilateral spatial neglect (USN )has not been studied. The main objective of this study was to investigate the influence of changing 3 postures on 4 standardized tests for USN in patients with ischemic stroke. Methods Nine patients with ischemic stroke (age, 73.4 ± 4.1 years, mean ± SE) were recruited.Inclusion criteria were awakeness, right-handedness before stroke, left hemiparesis due to right hemisphere lesion induced by cerebral infarction, and ability to undergo the tests for USN. 4 tests (Bells Test, Line Bisection, Scene Copy, and Star Cancellation) were conducted in supine, sitting and standing positions.Each subject was tested in 3 positions at random and completed all tests in the same day. Results The mean value of each test in standing position was significantly smaller than in sitting position （p<0.05）. However, the results of 4 tests in standing position were similar to those of supine position. Conclusion The standing position improved rightward deviation relative to sitting position in patients with ischemic stroke. However, there were no differences between supine and standing position. These results might be due to afferences arising from muscle spindle, Golgi tendon organ, and muscle contraction.
Purpose:Working memory, which plays an important role in higher brain function, represents the immediate memory process that allows simultaneous storage and processing of information. Presurgical identification of the central executive system in working memory is key to preserving higher brain function during brain tumor surgery. We developed a novel counting task (digit-span task) performed during fMRI for detecting the functional location of working memory, and evaluated its usefulness in brain tumor cases. Material and Methods:Four patients with brain tumor who were scheduled for tumor resection via awake surgery were enrolled. fMRI was performed using a 3-T MRI scanner, and the tasks included conventional language tasks (verb generation, object naming, reading, and listening) and a counting task for evaluating working memory. The counting task consisted of task A (counting backward) and task B (counting forward) , and subtraction A from B was performed. The activated areas were anatomically evaluated and compared to those activated during other tasks. Results:Significant activation was seen in the left dorsal prefrontal cortex (4/4 cases) , left anterior cingulate gyrus (3/4) , and the area around the intraparietal sulcus (3/4) . These areas were mostlyinconsistent with those in standard language tasks, such as verb generation or object naming, but similar areas were activated during the reading task. Conclusion:These results indicate the possibility of localizing the functional area in working memory, especially verbal working memory, with a counting task during fMRI. This is a simple task useful for the presurgical evaluation of patients with brain tumors.
We performed language mapping to preserve communication ability in a patient with moderate aphasia symptoms caused by glioblastoma on the left temporal lobe, which was characterized by severe impairment of auditory language understanding, repetition and naming. The task was to “read aloud kanji words provided with pronunciation indicators”. In the language mapping, no clear positive observation was noted, and 90％ of the tumor was removed surgically. As a result, the subjectʼs reading function and communication ability were retained. These findings suggest that even with moderate aphasia, when the aim is to secure communication means, languagemapping can be performed effectively.
A 78-year-old right handed-patient showing progressive nonfluent aphasia following corticobasal syndrome (CBS) demonstrated diverse writing disorders. She developed speech and writing disorders as initial symptoms. SPECT showed decreased blood flow in the frontal, temporal, and parietal lobes.Hypoperfusion was more prominent in the left hemisphere. Her motor symptoms were more frequent on the right side. Language and neuropsychological tests revealed mild nonfluent aphasia, disorders of writing, apraxia, disability of kinetic reading, constructional deficit, and mild intellectual disability. Naming, repetition, and attentional abilities were preserved. The patient displayed diverse dysgraphia as follows; apraxic, spatial, afferent and lexical agraphias, paragraphia of Kana, and omission of Kana letters. The peripheral agraphia in this patient was apraxic agraphia due to dysfunction of the left parietal lobe, while spatial agraphia and afferent agraphia which showed addition and omission of strokes in Kanji writing could be caused by disability of the right hemisphere. As central agraphias, lexical agraphia in Kanji induced by impairment of the semantic system involving the left temporal lobe, paragraphia in Kana letters due to left frontal lobe damage, and omission of Kana letters possibly concerned with disturbance of bilateral frontal lobes were observed. Writing and copying of words or sentences were preserved. We proposed that her diverse agraphias with CBS could be associated with dysfunction of not only the left but also the right hemisphere, the latter being closely related to visuospatial function as well as visual and kinetic feedback.
We encountered a patient in whom symptoms specific to the left side of the buccal cavity persisted despite the disappearance of left-sided hemispatial neglect and asomatognosia caused by right middle cerebralartery infarction. We attempted to interpret these symptoms localized in the buccal cavity as left-sided hemispatial neglect. The patient was a 64-year-old right-handed female. She exhibited no marked motor or sensory disorders in the left buccal cavity. We performed oral stereognosis testing by giving the patient simulated alimentary boluses (spherical, pyramidal, and cubical) . The results of this testing revealed that the patient could not recognize shapes on the left side of the buccal cavity. During the test, the patient made statements such as, “I canʼt feel my left palate,” “I canʼt picture the simulated alimentary bolus in my left side,” and “the simulated alimentary bolus disappears on the left side.” Furthermore, testing that involved drawing a body image of the buccal cavity also suggested the presence of an abnormality. The buccal cavity can be considered a space that envelops multiple oral organs. It cannot be concluded that the symptoms localized in the left side of the buccal cavity in the present case were caused by motor or sensory disorders or tactile agnosia of any part of the patientʼs oral cavity. Considering the buccal cavity as a space in which multiple oral organs are involved, we attempted to interpret the symptoms of the present case as buccal cavity left-sided spatial neglect, in which the aforementioned representational space has become impaired.
We encountered a patient who presented with metamorphopsia and micropsia of physiognomy caused by cerebral infarction in the right retrosplenial region. The patient was a 75-year-old right-handed man who visited our hospital complaining that he perceived the left eye and eyebrow of others to be displaced downwards and smaller than actual size. Neurological testing revealed metamorphopsia and micropsia of physiognomy. No abnormalities were seen in regard to visual acuity, visual field, ocular movement, visual cognitive function or other factors. The patient also exhibited metamorphopsia and micropsia with regard to two-dimensional objects in photographs and comics, round three-dimensional objects, and objects displaying similar spatial characteristics to faces. Metamorphopsia and micropsia usually occur contralateral to the lesion. In the present case, however, symptoms occurred ipsilateral to the lesion;the patient had sustained an injury to the right hemisphere, and perceived the left eyebrow and eye of others, which appeared in his right visual field, to be smaller than actual size. In this case, metamorphopsia and micropsia of physiognomy were thought to have occurred due to impairment induced by a lesion in the retrosplenial region involved in the integration of visual information between the left and right hemispheres, which specialize in recognizing the eyes, eyebrows, and contours, as well as objects having similar characteristics to these features.