The latest medical research on Brain Injury Medicine
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Request AccessSports-Related Concussion in Collegiate Athletes: The Potential Benefits of Using Graded Neuropsychological Tests With High Ceilings.
Journal of Head Trauma RehabilitationSports-related concussion management in collegiate athletes has been focused on return-to-play. However, resuming schoolwork without a gradual stepwise reintroduction contributes to symptom exacerbation, delayed recovery, and adverse academic performance. Return-to-learn guidelines are limited by a lack of sensitivity in methods monitoring cognitive function. This study evaluated 2 neuropsychological tests, the Sternberg test and the Paced Auditory Serial Addition Test (PASAT), with high ceilings for sensitivity to deficits in speed of information processing, cognitive efficiency, and complex attention.
The PASAT assesses complex attention. The Sternberg test examines processing speed and cognitive efficiency. Cognitive difficulty increases with progression through the tasks for both the PASAT and the Sternberg test. The mean outcome differences of the 3 groups (nonconcussed, acute, and chronic) across the 3 or 4 conditions (difficulty level) were measured with repeated-measures analysis of variance and subsequent pairwise comparison.
For processing speed (Sternberg reaction time), the acute group responded slower than the chronic group on the medium (P = .021, Bonferroni corrected) and hard difficulty tasks (P = .030, Bonferroni corrected). For cognitive efficiency (Sternberg reaction time variability), the acute group had increased reaction time variability compared with the chronic group on the medium difficulty task (P = .04, Bonferroni corrected). For complex attention (PASAT omissions), there was a difference between the acute and nonconcussed groups on the moderate-hard difficulty trial (P = .023, least significant difference [LSD] corrected) and between the acute and chronic groups for hard difficulty trial (P = .020, LSD corrected). The acute group performed worse, with progressively shorter interstimulus intervals.
Neuropsychological testing without ceiling effects can capture higher-level cognitive dysfunction and use of such tests can contribute to the understanding of how collegiate athletes are affected by SRC. Future studies can investigate optimal testing batteries that include neuropsychological testing with high ceilings and whether the pattern of performance has implications for the return-to-learn process after SRC in the college setting.
Characterization of an Algorithm for Autonomous, Closed-Loop Neuromodulation During Motor Rehabilitation.
Neurorehabilitation and Neural RepairRecent evidence demonstrates that manually triggered vagus nerve stimulation (VNS) combined with rehabilitation leads to increased recovery of upper limb motor function after stroke. This approach is premised on studies demonstrating that the timing of stimulation relative to movements is a key determinant in the effectiveness of this approach.
The overall goal of the study was to identify an algorithm that could be used to automatically trigger VNS on the best movements during rehabilitative exercises while maintaining a desired interval between stimulations to reduce the burden of manual stimulation triggering.
To develop the algorithm, we analyzed movement data collected from patients with a history of neurological injury. We applied 3 different algorithms to the signal, analyzed their triggering choices, and then validated the best algorithm by comparing triggering choices to those selected by a therapist delivering VNS therapy.
The dynamic algorithm triggered above the 95th percentile of maximum movement at a rate of 5.09 (interquartile range [IQR] = 0.74) triggers per minute. The periodic algorithm produces stimulation at set intervals but low movement selectivity (34.05%, IQR = 7.47), while the static threshold algorithm produces long interstimulus intervals (27.16 ± 2.01 seconds) with selectivity of 64.49% (IQR = 25.38). On average, the dynamic algorithm selects movements that are 54 ± 3% larger than therapist-selected movements.
This study shows that a dynamic algorithm is an effective strategy to trigger VNS during the best movements at a reliable triggering rate.
Prevalence and Correlates of VA-Purchased Community Care Use Among Post-9/11-Era Veterans With Traumatic Brain Injury.
Journal of Head Trauma RehabilitationPost-9/11-era veterans with traumatic brain injury (TBI) have greater health-related complexity than veterans overall, and may require coordinated care from TBI specialists such as those within the Department of Veterans Affairs (VA) healthcare system. With passage of the Choice and MISSION Acts, more veterans are using VA-purchased care delivered by community providers who may lack TBI training. We explored prevalence and correlates of VA-purchased care use among post-9/11 veterans with TBI.
Proportions of veterans who used VA-purchased care and both VA-purchased and VA-delivered outpatient care, overall and by study year. We employed multivariable logistic regression to assess associations between veterans' sociodemographic, military history, and clinical characteristics and their likelihood of using VA-purchased care from 2016 through 2019.
Overall, 51% of veterans with TBI used VA-purchased care during the study period. Nearly all who used VA-purchased care (99%) also used VA-delivered outpatient care. Veterans' sociodemographic, military, and clinical characteristics were associated with their likelihood of using VA-purchased care. Notably, in adjusted analyses, veterans with moderate/severe TBI (vs mild), those with higher health risk scores, and those diagnosed with posttraumatic stress disorder, depression, anxiety, substance use disorders, or pain-related conditions had increased odds of using VA-purchased care. Additionally, those flagged as high risk for suicide also had higher odds of VA-purchased care use.
Veterans with TBI with greater health-related complexity were more likely to use VA-purchased care than their less complex counterparts. The risks of potential care fragmentation across providers versus the benefits of increased access to care are unknown. Research is needed to examine health and functional outcomes among these veterans.
Associations Between Traumatic Brain Injury and Severity of Tinnitus-Related Functional Impairment Among US Military Veterans: A National, Population-Based Study.
Journal of Head Trauma RehabilitationTo describe associations between a history of traumatic brain injury (TBI) and the severity of tinnitus-related functional impairment among a national, stratified random sample of veterans diagnosed with tinnitus by the Department of Veterans Affairs (VA) healthcare system.
TBI history was assessed using International Classification of Diseases (ICD) diagnosis codes in veterans' VA electronic health records. The severity of participants' overall tinnitus-related functional impairment was measured using the Tinnitus Functional Index. Population prevalence and 95% confidence intervals (CIs) were estimated using inverse probability weights accounting for sample stratification and survey nonresponse. Veterans' relative risk ratios of very severe or moderate/severe tinnitus-related functional impairment, versus none/mild impairment, were estimated by TBI history using bivariable and multivariable multinomial logistic regression.
The population prevalence of TBI was 5.6% (95% CI: 4.8-6.4) among veterans diagnosed with tinnitus. Veterans with a TBI diagnosis, compared with those without a TBI diagnosis, had 3.6 times greater likelihood of rating their tinnitus-related impairment as very severe (95% CI: 2.1-6.3), and 1.5 times greater likelihood of rating their impairment as moderate/severe (95% CI: 1.0-2.4), versus none/mild.
These findings suggest an important role of TBI in the severity of tinnitus-related functional impairment among veterans. This knowledge can help inform the integration of tinnitus management services into the care received by veterans with TBI.
Associations of Nightmares and Sleep Disturbance With Neurobehavioral Symptoms Postconcussion.
Journal of Head Trauma RehabilitationThis study investigates the association of nightmares beyond general sleep disturbance on neurobehavioral symptoms in adults with mild traumatic brain injury (mTBI).
Behavioral Assessment Screening Tool, Pittsburgh Sleep Quality Index, and self-report of nightmare frequency in the past 2 weeks.
Among adults with mTBI, nightmares accounted for the greatest amount of variability in negative affect (β = .362, P < .001), anxiety (β = .332, P < .001), and impulsivity (β = .270, P < .001) after adjusting for age and sex. Overall sleep disturbance had the strongest association with depression (β = .493, P < .001), fatigue (β = .449, P < .001), self-reported executive dysfunction (β = .376, P < .001), and overall burden from concussive symptoms (β = .477, P < .001).
Nightmares and sleep disturbance are differentially associated with variance in neurobehavioral symptoms. Nightmares were independently associated with neurobehavioral symptoms representing an excess of normal functioning (eg, anxiety, impulsivity), while general sleep disturbance was associated with neurobehavioral symptoms representing functioning below normal levels (eg, depression, fatigue, self-reported executive dysfunction). Clinical and research implications are discussed.
The Use of Methylphenidate During Inpatient Rehabilitation After Pediatric Traumatic Brain Injury: Population Characteristics and Prescribing Patterns.
Journal of Head Trauma RehabilitationTo understand how methylphenidate (MPH) is used in youth with traumatic brain injury (TBI) during inpatient pediatric rehabilitation.
Patient demographic data, time to inpatient pediatric rehabilitation admission (TTA), cognitive state, MPH dosing (mg/kg/day).
Patients who received MPH were older (P = .011); TTA was significantly longer in patients who received MPH than those who did not (P =.002). The lowest recorded dose range by weight was 0.05 to 0.89 mg/kg/d, representing an 18-fold difference; the weight-based range for the maximum dose was 0.11 to 0.97 mg/kg/d, a 9-fold difference. Patients in lower cognitive states at admission (P = .001) and at discharge (P = .030) were more likely to receive MPH. Five patients had side effects known to be associated with MPH; no serious adverse events were reported.
This multicenter study indicates that there is variable use of MPH during acute inpatient rehabilitation for children with TBI. Children who receive MPH tend to be older with lower cognitive states. Dosing practices are likely consistent with underdosing. Clinical indications for MPH use during inpatient pediatric rehabilitation should be better defined. The use of MPH, as well as its combination with other medications and treatments, during inpatient rehabilitation needs to be further explored.
Applying the Common-Sense Self-Regulation Model to Understand Illness Representations of Mild Traumatic Brain Injury in College Students.
Journal of Head Trauma RehabilitationThe Common Sense Model (CSM) describes cognitive, emotional, and psychosocial factors that influence how health threats are processed and subsequently inform health-related decisions or actions. The purpose of this study was to examine psychosocial factors influencing coherence, or usefulness, of mild traumatic brain injury (mTBI) representations and their relationship to health-related decisions and actions.
Seven common injury mechanisms representative of university student mTBI experiences were presented as vignettes (cause). Each vignette included open- and closed-ended questions framed from CSM constructs (identity, consequences, action plans, timeline, and social context). Data were analyzed using a series of chi-square tests and multiple analysis of variance. Post hoc analysis identified differences in the injury vignettes.
Students were more likely to identify the injury as mTBI ( = 8.62, P = .035) and recommend immediate healthcare (F1,415 = 316.89, P < .001) for all causes if the injury occurred to a friend as compared with themselves. Action plans also varied by cause, with post hoc analysis revealing a higher likelihood of healthcare seeking for motor vehicle crashes and assault and a lower likelihood for falls while intoxicated. Students were generally more likely to talk to closest confidants than doctors (F8,398 = 33.66, P < .001).
Cause appears to be a key construct in generating illness representations and associated action plans for seeking care, with lower perceived severity causes (eg, falls) resulting in little to no health-seeking action. In addition, social support appears to be important for college students when making decisions about their health.
Presence of Self-Reported Sleep Alterations After Stroke and Their Relationship With Disability: A Longitudinal Study.
Neurorehabilitation and Neural RepairSleep disorders have a prevalence of 30% to 70% in post-stroke individuals. The presence of sleep disorders and poor sleep quality after stroke can affect important functions and lead to worse outcomes. However, most studies are restricted to the acute post-stroke stage only.
To investigate the frequency of self-reported sleep alterations in a sample of chronic stroke individuals and to identify which self-reported sleep alterations were associated with disability.
Prospective exploratory study. Self-reported sleep alterations were measured by the Pittsburgh Sleep Quality Index, Insomnia Severity Index, Epworth Sleepiness Scale, and STOP-Bang Questionnaire. The dependent variable was measured 3 years after the first contact by the Modified Rankin Scale (mRS). Step-wise multiple linear regression analysis was employed to identify which sleep alterations were associated with disability.
Sixty-five individuals with stroke participated. About 67.7% of participants had poor sleep quality, 52.4% reported insomnia symptoms, 33.9% reported excessive daytime sleepiness, and 80.0% were classified as intermediate or high risk for obstructive sleep apnea. Only risk for obstructive sleep apnea was significantly associated with disability and explained 5% of the variance in the mRS scores.
Self-reported sleep alterations had a considerable frequency in a sample of chronic stroke individuals. The risk of obstructive sleep apnea was associated with disability in the chronic stage of stroke. Sleep alterations must be considered and evaluated in the rehabilitation process even after a long period since the stroke onset.
Neural Mechanisms Associated With Postural Control in Collegiate Soccer and Non-Soccer Athletes.
Journal of Neurologic Physical TherapySport-specific training may improve postural control, while repetitive head acceleration events (RHAEs) may compromise it. Understanding the neural mechanisms underlying postural control may contextualize changes due to training and RHAE. The goal of this study was to determine whether postural sway during the Balance Error Scoring System (BESS) is related to white matter organization (WMO) in collegiate athletes.
Collegiate soccer (N = 33) and non-soccer athletes (N = 44) completed BESS and diffusion tensor imaging. Postural sway during each BESS stance, fractional anisotropy (FA), and mean diffusivity (MD) were extracted for each participant. Partial least squares analyses determined group differences in postural sway and WMO and the relationship between postural sway and WMO in soccer and non-soccer athletes separately.
Soccer athletes displayed better performance during BESS 6, with lower FA and higher MD in the medial lemniscus (ML) and inferior cerebellar peduncle (ICP), compared to non-soccer athletes. In soccer athletes, lower sway during BESS 2, 5, and 6 was associated with higher FA and lower MD in the corticospinal tract, ML, and ICP. In non-soccer athletes, lower sway during BESS 2 and 4 was associated with higher FA and lower MD in the ML and ICP. BESS 1 was associated with higher FA, and BESS 3 was associated with lower MD in the same tracts in non-soccer athletes.
Soccer and non-soccer athletes showed unique relationships between sway and WMO, suggesting that sport-specific exposures are partly responsible for changes in neurological structure and accompanying postural control performance and should be considered when evaluating postural control after injury.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content, available at: http://links.lww.com/JNPT/A472).
"They Just Love Me"-An Examination of Social Support Experiences and Values Among People With TBI.
Journal of Head Trauma RehabilitationSocial support is important for health and functional outcomes after traumatic brain injury (TBI), but many adults with TBI report inadequate social support. Little research has examined the social support priorities of adults with TBI or what an optimal social support network should include. The objective of this study was to describe the social support structures and experiences of adults with TBI.
Number of close social contacts and total social contacts, along with a report of the frequency of social support using the Medical Outcomes Study Social Support Survey. Qualitative interviews were used to examine the quality of social support and participant values and priorities.
Participants had an average of 4.3 close contacts (median 3.5, range 1-10), an average of 8.5 total social contacts (median 7, range 2-28), and a low frequency of social support (mean 28.4, SD = 24.7). Interview themes fell under 2 grand themes: structure of social networks (social networks are made up of families; proximity influences the type of support) and quality of social support (commitment vs indifference; doing things with and for others adds meaning; and "they just love me").
Participants in this study had small social networks and a low frequency of social support. Findings suggest that people with TBI value committed support partners, social inclusion, bidirectional relationships, and emotional connection, yet experience lower support in these areas compared to tangible support. Future research should examine how to adapt existing models of social support to more closely align with participant values. Rehabilitation services may need to focus more heavily on individual and family training, addressing strategies to develop and maintain relationships, emotional connection, and communication to enhance relationship and social support quality.
Bicycling for Rehabilitation of Persons With Parkinson Disease: A Scoping Review.
Journal of Neurologic Physical TherapyExercise is beneficial for persons with Parkinson disease (PwPD). The overarching purpose of this scoping review was to provide guidance to clinicians and scientists regarding current evidence for bicycling exercise for PwPD. A scoping review was conducted to examine the heterogeneous literature on stationary bicycling for PwPD to reduce motor symptoms and body function structure impairments, improve activities and motor performance, and reduce disease severity.
The Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines were followed. PubMed, CINAHL, and PEDro were searched from inception to January 23, 2023. Articles reporting original data on relevant outcome measures were included. Search results were screened and articles were extracted. Data were analyzed quantitatively with percentages of significant and clinically meaningful findings and qualitatively to extract themes.
Bicycling was categorized using bicycle types (assisted, nonassisted) and training modes (speed, aerobic, force). A high percentage of the 34 studies showed statistical significance for reducing motor symptoms (83%), body function structure impairments (78%), disease severity (82%), and improving activities (gait 72%, balance 60%). Clinically meaningful findings were achieved in 71% of the studies for reduction in disease severity and in 50% for improving gait.
The literature on bicycling for PwPD has evolved from speed to aerobic studies. The terminology describing types of bicycling was simplified. Of all the outcomes reported, reduction of disease severity achieved the highest frequency of clinical meaningful improvements. Bicycling was comparable with other forms of aerobic training for walking speed and endurance. Opportunities for translation to practice and research are presented.
for more insights from the authors (see the Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A462).
Effectiveness of Motor Imagery in the Rehabilitation of People With Parkinson's Disease: A Systematic Review and Meta-Analysis.
Neurorehabilitation and Neural RepairWith more research completed using Motor imagery (MI) in people with Parkinson's disease, this study gathered and synthesized evidence on the use of MI for Parkinson's disease in improving rehabilitation outcomes.
Medical Literature Analysis and Retrieval System Online, Embase, Web of Science, The Cochrane Library, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, and Scopus were searched from inception to May 2023. We included randomized controlled trials that examine the effects of MI on individuals with Parkinson's disease. Two reviewers selected articles and extracted study characteristics and results independently. The Physiotherapy Evidence Database scale was used to assess the methodological quality. Mean differences and 95% confidence intervals were calculated. Heterogeneity was assessed using the I2 statistic.
Thirteen articles with 12 studies were included, involving 320 individuals with Parkinson's disease, with moderate to high methodological quality (mean = 6.62/10). Compared with the control group, 3 articles reported significant greater improvements in cognitive function, 7 reported significant greater improvement in motor function, 1 article reported significant greater improvement in quality of life, and 1 reported significant greater confidence in daily task performance. No statistically significant effects were found in the meta-analyses. Conclusion. Results of individual articles were in favor of the MI intervention. No statistically significant results were found in the meta-analyses. This might be due to the small number of studies and the heterogeneity of interventions and outcome measures used. MI may be effective in improving some rehabilitation outcomes, but meta-analytic evidence is lacking. More research with larger sample size and less heterogeneous samples, interventions, and outcome measures, is warranted.
PROSPERO registration number CRD42021230556.
