There has been significant emphasis on the topic of Traumatic Brain Injury (TBI) for returning US Service Members from the wars in Iraq and Afghanistan due to the high frequency of exposure to blast explosions. TBI has been called the “signature wound” of these conflicts and there is considerable debate on the prevalence of TBI, as well as the contribution of TBI to current symptoms that former Active Duty Service Members are experiencing after returning from deployment. TBI is graded in severity based on duration of alteration or loss of consciousness, duration of post-traumatic amnesia, and Glasgow Coma Scale score.
    The Veterans Affairs TBI Screening and Evaluation process was initiated to identify those individuals with possible TBI and then confirm the diagnosis by an in-person examination by a clinician with TBI expertise. The efforts of the VA to identify and care for Veterans with TBI will be discussed as well as the challenges of diagnosis and treatment of mild TBI and the frequently occurring co-morbidities of pain, PTSD, and other mental health issues. The VA/DoD Clinical Practice Guidelines for the treatment and management of mild TBI/Concussion provide recommendations for treatment and will be briefly reviewed. Veterans with a history of mild TBI and persistent symptoms are being identified by the VA which provides an additional opportunity to provide needed services for this patient cohort.
    This article is an overview of the lecture presented as the Special Guest Speaker at the 34^th Annual Conference of the Japan Higher Order Brain Dysfunction Society.

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The purpose of this study was to investigate the incidence of higher brain dysfunction (HBD) that requires specific rehabilitative treatments and specialized social support. Convalescent rehabilitation hospitals and others in Fukuoka Prefecture were asked to register patients with moderate HBD on an internet web site. The study registered patients between 6 and 69 years of age that were residents of the prefecture and met the diagnostic criteria established by the HBD research group, with onset between June 2007 and May 2008. There were 114 patients registered with moderate HBD, and the incidence was 2.3/100,000 population, based on the population of Fukuoka Prefecture (5,060,000). Therefore, the annual frequency of new patients with moderate HBD in Japan was regarded as 2,884.

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The aim of this study was to review the progress of measures and the employment measures of support for people with higher brain dysfunction (HBD) in Japan, and to reveal the actual conditions of vocational support for people with HBDs provided at healthcare facilities and the support provided at vocational support facilities. In this study, a survey of 592 rehabilitation hospitals nationwide and 52 local vocational centers for persons with disabilities was conducted. The survey found that rehabilitation healthcare facilities and vocational support facilities had not been building up a cooperative relationship which is necessary to provide vocational support for people with HBDs. The paper summarized, based on the results of the survey, the challenges of establishing a cooperative system between those facilities, and proposed what the support for people with HBDs should be in future.

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Following the Road Traffic Act revised in June 2002, disqualification provisions have been applied to medical conditions of dementia including Alzheimer's disease and vascular dementia. On the other hand, those with cognitive and/or behavioral problems following traumatic brain injury, cerebrovascular diseases, encephalitis, etc. are relative, but not absolute disqualification reasons for driving license. However, there exist no decisive clinical criteria that determine the driving fitness of so-called “higher brain dysfunction” individuals. In this article, activities and situations of the driving evaluation clinic at Showa University were introduced and several characteristic individuals with higher brain dysfunction were reviewed. It is of great importance that we consider multidisciplinary approaches for the safety of automobile driving of cognitively handicapped individuals.

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Returning US Service Members from the wars in Iraq and Afghanistan have experienced an extremely high number of injuries, often blast-related which include Traumatic Brain Injury (TBI), Post Traumatic Stress Disorder (PTSD), and chronic pain. Additionally among these potential hundreds of thousands of Service Members with TBI, the majority experience mild Traumatic Brain Injury (mTBI) and are capable of a return to university studies and lifelong careers. The MindKnit Research Center is developing partnerships for sharing interdisciplinary research, integrated healthcare and university reintegration, models to recruit and train mentors, such as from the national Volunteer Portal under the White House with over 220,000 volunteers. Additionally, the Japan NRCD has partnered together with MindKnit Research Center and the US Veterans Health Affairs to build and sustain a vibrant “US-Japan Exchange” to share US and Japanese research, clinical, rehabilitation, reintegration and cultural models and national healthcare models to benefit both the hundreds of thousands of Service Members with TBI, but also the hundreds of thousands of persons with Brain Injury in Japan, and the 1.7 million persons with Brain Injury in the United States. Finally, this paper addresses a national Veterans Affairs healthcare study to build a nationwide model for Supported Education systems partnering the VA healthcare, university faculty and leaders, and potentially community experts such as the MindKnit Research Center and the White House Volunteer Portal-to provide successful reintegration to university for the hundreds of thousands of capable Service Member with TBI. This paper was presented as the US Co-Moderator of the Japan-US Exchange at the 34th Annual Conference of the Japan Higher Brain Disorder Society.

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Providing excellent medical care and support for returning Active Duty Service Members from the conflicts in Iraq and Afghanistan remains a high priority for the Department of Defense (DoD) and the Department of Veterans Affairs (VA). Current literature reports a high frequency of multiple co-morbid conditions including traumatic brain injury (TBI), post traumatic stress disorder (PTSD), and chronic pain. Symptoms from these three conditions can become barriers to successful return to work and school. Common symptoms will be reviewed with discussion on rehabilitative efforts to overcome these barriers. Ideal management of this re-integration is best handled in an interdisciplinary manner by an experienced rehabilitation team. This article reviews the presentation “TBI and Polytrauma : Challenges Associated with Community Reintegration” presented at the 34^th Annual Congress of the Japan Higher Order Brain Dysfunction Society as part of the Japan-US Exchange.

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Spoken word production in people with aphasia was discussed in relation to some typical speech symptoms. They might be the end results of dynamic interactions of phonological, morphological, syntactic, semantic, and pragmatic functions as well as various cognitive functions underlying language processes, accompanying motor speech disorders, nonverbal communication, and psychosocial aspects. It is not easy to detect such factors and their dynamics through observable speech symptoms.

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Information processing involved in the auditory comprehension of language is reviewed. The process begins with capturing word sounds in which meanings are encoded and ends with the decoding of meanings from these word sounds. From the cognitive neuropsychological standpoint, the process of auditory comprehension of language can be divided into five steps, i. e., (1) capturing vocal sounds from the outside world by the brain (word sound processing), (2) categorization of the vocal sounds and matching them to templates (Japanese phonemes), (3) lexical/semantic processing, (4) parsing, and (5) analysis of discourse. In this article, the underlying mechanisms and neural correlates of each step are discussed. When the logogen model designed for English (a syllabic language) is applied to Japanese mora language for the purpose of explaining the mechanisms of information processing in Japanese, some discrepancies arise. Accordingly, a new logogen model for Japanese as mora language is proposed.

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    To discuss reading in aphasia, we first introduced a simple model of cognitive neuropsychology, and presented properties of Japanese characters (Kanji and Kana). We identified some similarities and differences between confrontation naming and oral reading, and pointed out that phonological dyslexia is attributed not to phonological disturbance but to disturbance of grapheme-phoneme-conversion (GPC).
    Furthermore, we suggested that Kana should be used more positively for aphasia therapy as part of reading-based approaches, because we found the effectiveness of connecting Kanji to meaning and Kana to phonological representations, which helps an individual to associate representations of grapheme, meaning, and phoneme to compose a “lexicon”. Also, we proposed some varieties of Kana-using therapy for auditory comprehension and speech production to facilitate theory-based practices.

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Writing ability develop based on acquiring oral language, and writing disturbances due to brain damages may be closely related with oral language performances. Brain lesions caused writing disturbances are supposed in the left hemisphere, i. e. the operculum of the second frontal gyrus, the angular gyrus, the superior parietal lobule and the inferior posterior temporal area. These areas are adjacent to language areas such as Broca's area and Wernicke's area, and then aphasics may reveal various types of disturbances in writing, including impairments of retrieval and/or selection of letters/words. In this paper, the author presents examples of writing errors in aphasia.

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We reported a patient with cerebral infarction who showed foreign accent syndrome (FAS) without dysarthria or other aphasic symptoms. A 47-year-old, corrected right-handed male developed articulatory difficulty and right hemiplegia with right central facial paralysis. MR imaging showed a left frontal infarction including the middle and inferior parts of the precentral gyrus. On the 5th day from onset, his speech showed mild anarthria including irregular articulatory distortion, substitution and repetition of initial sounds. The anarthria subsided during the next 10 days. Disturbance of prosody, however, became apparent in his spontaneous speech, reading aloud, and repetition of words and short sentences. Word accent often shifted and a word often had two units of accent. His rate of speech also increased. Both the examiners and his family members felt his speech seemed that of a foreigner. The dysprosodic speech subsided over the course of the next 6 months. The characteristics of the patient's dysprosody were different from either those of anarthria or those of aprosodia associated with right hemisphere lesions, and we considered his dysprosody to be foreign accent syndrome.

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We undertook a long-term recovery case study of a 46-year-old, right-handed male with severe motor aphasia, severe apraxia of speech, and severe oro-facial apraxia. He developed aphasia and right hemiplegia following a cerebral hemorrhage in the left hemisphere. CT images demonstrated a large lesion extending to the basal ganglia, and the frontal, temporal and parietal lobes of the left hemisphere. At 8 months after onset, we started examination of impairments of his language and speech, as well as related training. His impairments were examined using the Standard Language Test for Aphasia (SLTA) and assessment lists for apraxia of speech. The standard treatment for aphasia was initiated 8 months after the onset, in parallel with systematic articulation treatment. Upon initial testing, he could produce a few distorted vowels but no consonants. After a 4-year course of treatment, the results of SLTA showed conspicuous improvements in items related to speaking and writing. His speech improved from 5 to 3 in conversational discourse intelligibility rating. The variety of sounds that he can articulate voluntarily also expanded. Performance on the SLTA indicates recovery extends over a long period, with the course and time of recovery varying according to language and speech modalities.

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In this paper we studied errors found in an Arabic numeral dictation experiment conducted on a conduction aphasic patient and a Broca's aphasic patient, and examined the features and occurrence level of their errors from the perspective of their ability to process digits and numerical positioning. We devised and executed the following two kinds of test on the two patients: “dictation test of Arabic numerals”, which both included and excluded zero (0) numerals ; and a “digit & numerical positioning test”, which examined the processing of digits and their numerical positioning separately. Results showed that the conduction aphasic patient presented many errors in digits, while the Broca's aphasic patient presented errors in both digits and numerical positioning. The digit errors presented by both patients occurred in the repetitive level of the auditory stimulus before it was written down, while the numerical positioning errors of the Broca's aphasic patient occurred in the level at which the Arabic number was written after it had been repeated. These results suggest that the digit errors in both cases were a processing deficit of the digit in the Verbal Word Frame of the Triple-Code Model (Dehaene et al.,1995) ; the numerical positioning errors of the Broca's aphasic patient were thought to be a processing deficit of numerical positioning in the Visual Arabic Number Form of the model concerned.

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Objective: To evaluate the validity of Self-care Rating for Dementia Extended (SCR-DE), an extensive scale of basic self-care abilities that reflects executive function and dysfunction. Subjects : Thirty-one community-dwelling patients with Alzheimer's disease who had reliable informants for this study. Methods : In SCR-DE, which is a semi-structured interview with an informant, a rater read the criteria of the rating to each informant if necessary and then assessed each patient. We supplemented descriptions for the criteria of grades 2 and 3 of eating ability in the SCR-DE based on the previous study. The relationship between the grades of each assessment item (dressing, bathing, grooming, eating, toileting, and overall self-care) in the SCR-DE and the demographic, clinical and cognitive characteristics of the patients was examined. Results: All items of the SCR-DE significantly correlated with overall severity in the Clinical Dementia Rating (CDR) and the total score of the Dysexecutive Questionnaire for Dementia (DEX-D). Dressing, grooming, and overall self-care correlated significantly with the score of the ideational praxis task in the Alzheimer's Disease Assessment Scale (ADAS). The partial correlation coefficient between the total scores of the SCR-DE and the DEX-D was significant after excluding the effects of age and overall severity in multiple correlation analysis (r=.55,p <.05). Conclusion: SCR-DE correlated significantly with some indicators of executive dysfunction. The results demonstrated the sufficient validity of the SCR-DE as a scale reflecting executive dysfunction.

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