A new procedure for communication with a patient with minimal motor function and fatigability

As with eye movements in locked-in syndrome, severe motor dysfunction should be coped with by an agreed system of interpretation to express feelings and needs. However, it is possible that such patients might make errors in the agreed system of interpretation through fatigue, which would cause misunderstandings. We report here a new questioning and verifying strategy for an agreed system of interpretation. Our questioning strategy is characterized by repeating questions in different forms, specifically by affirmative and negative sentences (Double-Checked agreed system of interpretation). When the patient wants to express "Yes", a single movement is required for an affirmative question and no movement is required for a negative one. When the patient wants to express "No", no movement is required for an affirmative question and one movement is required for a negative one. The Double-Checked agreed system of interpretation can help patients to cope with fatigability and can also help to prevent misunderstandings. If the same responses to both affirmative and negative questions are given, we can consider that those answers reflect fatigue. In addition, we have developed a strategy to evaluate the patient's understanding of the Double-Checked agreed system of interpretation by modifying the Western Aphasia Battery. This report describes how to apply the Double-Checked agreed system of interpretation, using the example of a 48-year-old brain-injured man with minimal motor function and severe fatigability.