Posts Tagged Brain Injuries

[Abstract] Evidence-Based Cognitive Rehabilitation: Systematic Review of the Literature From 2009 Through 2014 – Archives of Physical Medicine and Rehabilitation

Abstract

Objective

To conduct an updated, systematic review of the clinical literature, classify studies based on the strength of research design, and derive consensual, evidence-based clinical recommendations for cognitive rehabilitation of people with TBI or stroke.

Data Sources

Online Pubmed and print journal searches identified citations for 250 articles published from 2009 through 2014.

Study Selection

186 articles were selected for inclusion after initial screening. 50 articles were initially excluded (24 healthy, pediatric or other neurologic diagnoses, 10 non-cognitive interventions, 13 descriptive protocols or studies, 3 non-treatment studies). 15 articles were excluded after complete review (1 other neurologic diagnosis, 2 non-treatment studies, 1 qualitative study, 4 descriptive papers, 7 secondary analyses). 121 studies were fully reviewed.

Data Extraction

Articles were reviewed by CRTF members according to specific criteria for study design and quality, and classified as providing Class I, Class II, or Class III evidence. Articles were assigned to 1 of 6 possible categories (based on interventions for attention, vision and neglect, language and communication skills, memory, executive function, or comprehensive-integrated interventions).

Data Synthesis

Of 121 studies, 41 were rated as Class I, 3 as Class Ia, 14 as Class II, and 63 as Class III. Recommendations were derived by CRTF consensus from the relative strengths of the evidence, based on the decision rules applied in prior reviews.

Conclusions

CRTF has now evaluated 491 papers (109 Class I or Ia, 68 Class II, and 314 Class III) and makes 29 recommendations for evidence-based practice of cognitive rehabilitation (9 Practice Standards, 9 Practice Guidelines and 11 Practice Options). Evidence supports Practice Standards for attention deficits after TBI or stroke; visual scanning for neglect after right hemisphere stroke; compensatory strategies for mild memory deficits; language deficits after left hemisphere stroke; social communication deficits after TBI; metacognitive strategy training for deficits in executive functioning; and comprehensive-holistic neuropsychological rehabilitation to reduce cognitive and functional disability after TBI or stroke.

via Evidence-Based Cognitive Rehabilitation: Systematic Review of the Literature From 2009 Through 2014 – Archives of Physical Medicine and Rehabilitation

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[Abstract] Advanced Therapy in Traumatic Brain Injury Inpatient Rehabilitation: Effects on Outcomes During the First Year after Discharge

Abstract

Objective

To use causal inference methods to determine if receipt of a greater proportion inpatient rehabilitation treatment focused on higher level functions, e.g. executive functions, ambulating over uneven surfaces (Advanced Therapy, AdvTx) results in better rehabilitation outcomes.

Design

A cohort study using propensity score methods applied to the TBI-Practice-Based Evidence (TBI-PBE) database, a database consisting of multi-site, prospective, longitudinal observational data.

Setting

Acute inpatient rehabilitation (IRF).

Participants

Patients enrolled in the TBI-PBE study (n=1843), aged 14 years or older, who sustained a severe, moderate, or complicated mild TBI, receiving their first IRF admission to one of 9 sites in the US, and consented to follow-up 3 and 9 months post discharge from inpatient rehabilitation.

Interventions

Not applicable. Main Outcome Measures: Participation Assessment with Recombined Tools-Objective-17, FIMTM Motor and Cognitive scores, Satisfaction with Life Scale, and Patient Health Questionnaire-9.

Results

Controlling for measured potential confounders, increasing the percentage of AdvTx during inpatient TBI rehabilitation was found to be associated with better community participation, functional independence, life satisfaction, and decreased likelihood of depression during the year following discharge from inpatient rehabilitation. Participants who began rehabilitation with greater disability experienced larger gains on some outcomes than those who began rehabilitation with more intact abilities.

Conclusions

Increasing the proportion of treatment targeting higher level functions appears to have no detrimental and a small, beneficial effect on outcome. Caution should be exercised when inferring causality given that a large number of potential confounders could not be completely controlled with propensity score methods. Further, the extent to which unmeasured confounders influenced the findings is not known and could be of particular concern due to the potential for the patient’s recovery trajectory to influence therapists’ decisions to provide a greater amount AdvTx.

via Advanced Therapy in Traumatic Brain Injury Inpatient Rehabilitation: Effects on Outcomes During the First Year after Discharge – Archives of Physical Medicine and Rehabilitation

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[ARTICLE] Thirty Years of National Institute on Disability, Independent Living, and Rehabilitation Research Traumatic Brain Injury Model Systems Center Research—An Update – Full Text

The Traumatic Brain Injury Model Systems Center (TBIMSC) program was established by the National Institute on Disability, Independent Living, and Rehabilitation Research in 1987, with the goal of conducting research to improve the care and outcomes for individuals with moderate-to-severe traumatic brain injury (TBI). This article provides an update on TBIMSC research program activities since 2010 when a similar article was published. It includes (1) discussion of TBIMSC program management and infrastructure; (2) detail on the management, data quality, access, use, and knowledge translation of the TBIMSC National Database, with more than 16 000 participants with follow-up out to 25 years postinjury to date; (3) an overview of the TBIMSC site-specific studies and collaborative module research; (4) highlights of several collaborative initiatives between the TBIMSCs and other federal, advocacy, and research stakeholders; (5) an overview of the vast knowledge translation occurring through the TBIMSC program; and (6) discussion of issues that impact on the data collection methods for and contents of the TBIMSC National Database. On the occasion of the 30th anniversary of the TBIMSC program, this article highlights many of the accomplishments of this well-established, multicenter TBI research consortium.

THE TRAUMATIC BRAIN INJURY MODEL SYSTEMS CENTER (TBIMSC) program was established by the National Institute on Disability and Rehabilitation Research (NIDRR) (now the National Institute on Disability, Independent Living, and Rehabilitation Research—NIDILRR) in 1987, with the goal of improving healthcare (especially rehabilitation care) and outcomes for patients with moderate-to-severe traumatic brain injury (TBI), providing patient/family and healthcare professional education, and conducting research. In a 2010 article, we described the origin, activities, and accomplishments of the TBIMSCs, with a particular emphasis on the research activities.1 This year’s 30th anniversary of the TBIMSC program is an appropriate time to update the history and achievements. We focus on the research activities of the TBIMSC program, that is, the site-specific studies, collaborative studies, and longitudinal National Database (NDB), as well as on the multifaceted knowledge translation initiatives. We also provide examples of the many ways in which the infrastructure of the TBIMSC program has been leveraged in collaborations with other TBI stakeholders.

NIDILRR, the funder of much rehabilitation research in the United States, established the TBIMSC program to demonstrate the value of coordinated medical, social, and vocational services for persons with a moderate-to-severe TBI, a group that had started receiving inpatient rehabilitation facility (IRF) services in the 1970s, rather than being placed in psychiatric hospitals or other long-term care facilities.2 Grants supporting demonstration, education, and research, made for 5-year periods, initially went to 5 academic medical centers or equivalent entities; the number has been expanded over time, and for the 2017-2022 grant cycle, the number of recipients is 16 (see Table 1). The requirement of grantees that research activities are connected to a clinical program with emergency, acute neurosurgical, and inpatient and outpatient rehabilitation services is still key. The research funded involves contributions to the longitudinal NDB and collaboration on analysis of its data; site-specific research; and participation in module projects, which are shorter-term research projects undertaken by 2 or more TBIMSCs. The close cooperation between TBIMSCs on the NDB and module studies and the availability of extensive information on the rehabilitation patients at each center have been instrumental in the development of additional joint research, funded by NIDILRR, Patient-Centered Outcomes Research Institute (PCORI), National Institutes of Health (NIH), Department of Defense (DoD), Centers for Disease Control and Prevention (CDC), and other agencies. These mechanisms are described later, with recent and current projects listed.

TABLE 1

TABLE 1

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MANAGEMENT

Management of joint activities involves the project directors (PDs) (principal investigators) of all TBIMSCs and their staff, collaborating in a number of standing and ad hoc committees, which communicate in twice-yearly, face-to-face meetings in Washington, District of Columbia, through regular conference calls and dozens of listservs. NIDILRR staff participate in most meetings, offering advice or clarifying agency objectives, rules and procedures. The staff of the TBI National Data and Statistical Center (NDSC), which is separately funded by NIDILRR, similarly play key roles, participating in management of and providing support for all multicenter activities. The 5 TBIMSC program’s standing committees are Executive, Planning, Research, Data, and Knowledge Translation (KT).

Special Interest Groups (SIGs) were first developed in 2008 to allow the TBIMSCs another avenue for research collaboration, focusing on developing new research efforts between centers as well as with outside entities. SIGs can be formed at any time, focus on mutual topics of interest to TBIMSC investigators, but do not necessarily conduct research, although research may result from their deliberations. SIGs are allotted time at PDs’ meetings and must also hold regularly scheduled conference calls to ensure continued progress toward stated goals. Currently active SIGs include the following: (1) Aging with TBI and TBI in the Elderly; (2) Analytic Procedures; (3) Caregiver and Family; (4) Cultural Issues; (5) Disorders of Consciousness; (6) PCORI; (7) Sleep-Wake-Fatigue; (8) Geographic Identifiers for Data Linkages; and (9) Department of Veterans Affairs (DVA) Collaboration.

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HISTORY 2010-2018

Move from the Department of Education to the Administration on Community Living

In October of 2014, NIDRR began the process of moving from the Department of Education (DoE) to the Administration on Community Living (ACL) within the Department of Health and Human Services (HHS). With the move to ACL came an increased focus on independent living, and “NIDRR” became “NIDILRR.” ACL combines the efforts of NIDILRR, the HHS Office on Disability, the Administration on Aging, and the Administration on Intellectual and Developmental Disabilities and serves as the agency responsible for increasing access to community supports, focusing on the needs of people with disabilities throughout their life span as well as those of older Americans; it also has oversight of the State Implementation and Protection and Advocacy TBI program grants.

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National Data and Statistical Center

Since 2006, Craig Hospital in Englewood, Colorado, has been funded via 5-year competitive awards from NIDILRR to serve as the TBIMSC NDSC. Major initiatives over the years have included a public and private Web site to describe the NDB and facilitate the work of the TBIMSCs; a Standard Operating Procedures (SOP) Manual with a Web-based template for all TBIMSC policies and procedures; a standardized follow-up interview, built into the data entry system; mechanisms to support defunded TBIMSCs to continue data collection with those participants already enrolled in the NDB; data collector certification processes; dynamic data summary reporting for each center and for the TBIMSCs as a whole; resources for improving cultural competency in TBI research; and the introduction of many advanced statistical methodologies to analyze the wealth of NDB longitudinal data. In the current NDSC funding cycle (2016-2021), major initiatives are the standardization of data curation and data sharing to support reproducible research, as well as collaboration with the NDSCs from the Spinal Cord Injury and the Burn Model Systems Center (MSC) programs to maximize standardization where possible and promote trauma injury research.

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TBI Interagency Conferences

NIDILRR and the TBIMSCs have a major role in the hosting of the TBI Federal Interagency Conferences through the efforts of the KT Committee. To date, 4 have been held in the Washington, District of Columbia, area (December 1999, March 2006, June 2011, and June 2018). The most recent one had participation from more than 30 federal agencies and institutions, including NIDILRR, CDC, DoD, DoE, DVA, Health Resources & Services Administration, and NIH. The interdisciplinary conference offers an opportunity for federal policy and research administration staff and the researchers they fund to learn about cutting-edge research and emerging evidence-based practices.

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Collaboration with the DVA Polytrauma Rehabilitation Centers

In 2005, the DVA established Polytrauma Rehabilitation Centers (PRCs), which focused on TBI after this became the signature injury of the Middle-East wars. In 2008, NIDILRR and the DVA signed an interagency agreement to create a database for the PRCs, which parallels the TBIMSC NDB. The NDSC created a separate but similar Web-based data management system and provides the same training, technical, and administrative support, SOP development, and data access as is afforded to the TBIMSCs. Four PRCs began enrollment in 2010: James A. Haley Veterans Hospital, Tampa, Florida (482 participants enrolled); Minneapolis VA Medical Center (138); Hunter Holmes McGuire VA Medical Center, Richmond, Virginia (213); and VA Palo Alto Health Care System, California (165). In 2014, the South Texas Veterans Health Care System joined this initiative; it has enrolled 84 participants. The active military and veteran participants are being followed at the same postinjury time points as the TBIMSC NDB (see later).

The collaboration between the DVA PRCs and the TBIMSC program has grown well beyond the parallel databases. The DVA PRCs have representation, including voting privileges, at the biannual TBIMSC meetings, and on TBIMSC committees and SIGs, including the DVA Collaboration SIG specifically designed as a mechanism to bring TBIMSC and DVA researchers together. In this collaboration, the VA PRCs are now referred to as the VA TBIMSCs, although funding for these centers remains separate from that for the (NIDILRR) TBIMSCs. To date, DVA researchers have initiated 27 analyses of the VA PRC database, with 8 already published; 3 analyses comparing the TBIMSC NDB with PRC NDB data have been completed or are under way.3–10

[…]

 

Continue —>  Thirty Years of National Institute on Disability, Independen… : The Journal of Head Trauma Rehabilitation

 

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[Review] Evidence-Based Cognitive Rehabilitation: Updated Review of the Literature From 2003 Through 2008

Abstract

Cicerone KD, Langenbahn DM, Braden C, Malec JF, Kalmar K, Fraas M, Felicetti T, Laatsch L, Harley JP, Bergquist T, Azulay J, Cantor J, Ashman T. Evidence-based cognitive rehabilitation: updated review of the literature from 2003 through 2008.

Objective

To update our clinical recommendations for cognitive rehabilitation of people with traumatic brain injury (TBI) and stroke, based on a systematic review of the literature from 2003 through 2008.

Data Sources

PubMed and Infotrieve literature searches were conducted using the terms attentionawarenesscognitivecommunicationexecutivelanguagememoryperceptionproblem solving, and/or reasoning combined with each of the following terms: rehabilitationremediation, and training for articles published between 2003 and 2008. The task force initially identified citations for 198 published articles.

Study Selection

One hundred forty-one articles were selected for inclusion after our initial screening. Twenty-nine studies were excluded after further detailed review. Excluded articles included 4 descriptive studies without data, 6 nontreatment studies, 7 experimental manipulations, 6 reviews, 1 single case study not related to TBI or stroke, 2 articles where the intervention was provided to caretakers, 1 article redacted by the journal, and 2 reanalyses of prior publications. We fully reviewed and evaluated 112 studies.

Data Extraction

Articles were assigned to 1 of 6 categories reflecting the primary area of intervention: attention; vision and visuospatial functioning; language and communication skills; memory; executive functioning, problem solving and awareness; and comprehensive-holistic cognitive rehabilitation. Articles were abstracted and levels of evidence determined using specific criteria.

Data Synthesis

Of the 112 studies, 14 were rated as class I, 5 as class Ia, 11 as class II, and 82 as class III. Evidence within each area of intervention was synthesized and recommendations for Practice StandardsPractice Guidelines, and Practice Options were made.

Conclusions

There is substantial evidence to support interventions for attention, memory, social communication skills, executive function, and for comprehensive-holistic neuropsychologic rehabilitation after TBI. Evidence supports visuospatial rehabilitation after right hemisphere stroke, and interventions for aphasia and apraxia after left hemisphere stroke. Together with our prior reviews, we have evaluated a total of 370 interventions, including 65 class I or Ia studies. There is now sufficient information to support evidence-based protocols and implement empirically-supported treatments for cognitive disability after TBI and stroke.

via Evidence-Based Cognitive Rehabilitation: Updated Review of the Literature From 2003 Through 2008 – Archives of Physical Medicine and Rehabilitation

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[ARTICLE] Post-Acute Traumatic Brain Injury Rehabilitation Treatment Variables: A Mixed Methods Study – Full Text

Abstract

Purpose

This study explores gains in function, measured by the Mayo-Portland Adaptability Inventory-4 (MPAI-4) and qualitative interviews, of individuals who participated in a Post Hospital Interdisciplinary Brain Injury Rehabilitation – Residential (PHIDBIR-R) program as part of their recovery from brain injury.

Methods

The study uses a mixed methods design to identify correlates and explore pathways to functional recovery. Change scores from the MPAI-4 were derived to identify participants with greatest functional improvement. Qualitative interviews were employed to understand PHIDBIR-R program constructs associated with functional improvement. MPAI-4 data were derived from a bank of 135 PHIDBIR-R programs in 22 states. Participants were adults who sustained a brain injury and participated in a PHIDBIR-R program. 57 participants were identified as highest scorers; 10 completed semi-structured interviews.

Results

Data were analyzed using constant comparison procedures and rigorous credibility techniques. Thirteen themes within four categories (support, therapies, continuum of care, environment of care) emerged, reflecting participants’ understanding of constructs contributing to positive outcomes.

Conclusions

The results provided a cogent framework for program development, stakeholder program selection, and advocate and legislator considerations.

INTRODUCTION

Traumatic brain injury (TBI) is an alteration in brain function or other evidence of brain pathology caused by an external force. These injuries manifest as mild, moderate, or severe impairments to one or more areas, such as cognition, communication, memory, concentration, reasoning, physical functions, and psychosocial behavior [1].
The consequences of brain injuries are numerous with the potential to create life-long challenges for survivors and their families. Stories involving TBI permeate the news: the high-school athlete concussed in a football game, the soldier wounded in an explosive blast, and the teenager injured in a car accident. In these scenarios, futures transition from navigating routine activities to struggling to function.
A formidable fact surrounding these circumstances is that brain injury does not discriminate – it can happen to any person, at any time. Each year in the United States, 1.7 million TBIs occur either as an isolated injury or in conjunction with other injuries or illnesses. In the U.S., TBI is a contributing factor to nearly a third (30.5%) of all injury-related deaths [2] and figures indicate that 5.3 million people live with a TBI-related disability [3]. Annually, TBIs cost Americans $76.5 billion in medical care, rehabilitation, and loss of work [4,5].
Other etiologies of brain injury further elevate these numbers. The annual incidence of stroke is 795,000 [6]. Further, the annual estimate of brain tumors is 64,530, along with 27,000 aneurysms, and 20,000 viral encephalitis cases [68]. No national data are available for anoxic brain injury and other subtypes [1]. When all types of brain injury are aggregated, the annual occurrence in the U.S. approaches 8.5 million.
In addition, brain injuries reach beyond the individual who has sustained the TBI, affecting the lives of loved ones. Grief-stricken families witness trauma, entering a reality in which survival is the daily hope. Improvements in medical care have improved life expectancy, yielding a steady increase in the number of older adults living with a brain injury [9,10].
Once evident that an individual will survive the brain injury, goals focus on regaining lost function or rehabilitation. Just as each individual is unique, so is each recovery. Families commonly observe physical disabilities, impaired learning, and personality changes post injury. Nearly 20 years ago, the National Institutes of Health held a conference wherein an expert panel recommended that patients with TBI receive an individualized rehabilitation program based on the patient’s unique strengths and capacities, and adapted to needs over time. The group further advised that persons with moderate to severe brain injuries have individually tailored treatment programs that draw on the coordinated skills of various specialists [11].
Past research of rehabilitation following brain injury has often focused on the evaluation of a specific treatment modality or of a program’s efficacy as quantified by outcomes measurements. Many studies have sought to determine if rehabilitation has been successful, perhaps to the detriment of learning how rehabilitation has been efficacious. Studying how rehabilitation works over time is important in learning more about the individual and family experience while advancing an understanding of measured functional improvements.
Current research explores the therapies and interventions that facilitate long-term recovery of function. Individuals follow diverse recovery paths because there are a wide variety of options for rehabilitation [12]. This study focuses on Post-Hospital Inter-Disciplinary Brain Injury Rehabilitation – Residential (PHIDBIR-R) programs, which are 24-hour, 7-days a week rehabilitative care programs delivered in non-hospital, home-like, community-based environments. PHIDBIR-R programs strive to implement effective therapeutic interventions, supports, and services that maximize functional gains; these programs are judged on their ability to produce improvements in function [13].
While research efforts have focused on demonstrating positive outcomes, the identification of attributes that contribute to how improvement happens is largely untouched [1318]. Although several PHIDBIR-R programs report positive outcomes [19,20], the empirical evidence is limited and studies habitually focus on quantitative analysis. Including a qualitative component may provide insight into the PHIDBIR-R, eludicating how these experiences advance an understanding of functional improvements. […]

Continue —> Post-Acute Traumatic Brain Injury Rehabilitation Treatment Variables: A Mixed Methods Study

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[Poster] Implementing Best Practices in Cognitive Rehabilitation: What are Rehabilitation Teams’ Priorities and Why?

via Implementing Best Practices in Cognitive Rehabilitation: What are Rehabilitation Teams’ Priorities and Why? – Archives of Physical Medicine and Rehabilitation

First page of article

This study represents the first step of a knowledge translation initiative to support the implementation of best practices in cognitive rehabilitation post-acquired brain injury (ABI). The objective was to identify rehabilitation teams’ priorities regarding the implementation of best practices in cognitive rehabilitation, as well as the factors influencing decision-making processes about implementation.

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[ARTICLE] Botulinum toxin type-A overdose for the treatment of spastic muscles in two patients with brain injuries – Full Text

Abstract

Spasticity is commonly encountered clinically, and always affects patients’ motor ability and capacity for self-care which necessitates intervention. At present, numerous methods have been proposed with varying effects. Many reports show that the most effective method is to inject botulinum toxin, type A (BTX-A) into the spasming muscles, but the doses are different. The guidline of BTX-A injection in Chinese adults is restricted to 600 IU each time within 3 months. In this article, we treated two brain injury patients with severe regional spasticity with overdose of China-making BTX-A whose trademark is HengLi. The treatment improved spasticity and with little adverse effects. We therefore conclude that overdoses of BTX-A could also be safe and more efficient used in some patients who are showing severe spasticity of limb muscles, but it should be vary with each individual and a large sample size trial is needed for a further confirmation.

Introduction

Spasticity often occurs after brain injury and always affects the motor ability and other function of the patient, thereby necessitating intervention in some cases. At present, the most effective method is injection of BTX-A in the spasming muscles. However, there is no unified guideline for the injection doses [1], the highest dosage for a single injection is less than 600 IU in Chinese guideline. So the most usage dose of BTX-A which injected to the spastic muscles of patient, was always 100-500 IU per time of per patient in our clinical work days, and sometimes it seems to take insufficient effects during a period of 2 weeks, the effect of BTA-A even last for more than 3 months.

So in patients with extensive or severe muscle spasm we decided to increase the dose of BTX-A. Although the halflethal dose of BTX-A is 40 IU/kg of body weight, which implies that a dose of BTX-A over 600 IU is safe, even a larger dose might be safe enough, but it is not confirmed yet, only few trials of small sample has been published, and the doses are less than that we used [2]. Thus, we tried administering higher BTX-A doses in two patients who had developed a severe regional spasticity after brain injury. To our knowledge, none of this kind of reports has been published yet.

Case Presentation

This study was conducted in accordance with the declaration of Helsinki, and it was conducted with approval from the Ethics Committee of the affiliated hospital of Qingdao University. Written informed consents were obtained from the participants. All procedures were performed with the consent of the patients and their family members.

Case 1

A 57-year-old man was admitted because of sudden glossolalia with choking and coughing while drinking, who was also unable to walk and swallow, had an over 10 years history of high blood pressure, but irregular use of antihypertensive agents. He was carried to our hospital for further rehabilitation after a preliminary treatment in a local hospital. Physical examination (PE) at admittance: BP 148/86 mmHg. The systolic pressure was a little higher, and his heart rate, rhythm and both the lungs were heard normal.

Nervous system examination (NSE): Although consciously, but the patient was anepia, depressed, and a little uncooperative on checking. His right nasolabial groove was relatively shallower, and poor tongue controlling. 0-1 grade muscle strength on his right side, and 3-4 grade on the left, increased muscle tone, and hyperactive tendon reflex, Modified Ashworth Scales (MAS) of both sides are range from 1+ to 2 grade. Right Babinski’s sign was positive (+), but the left was doubtful positive (±). Thus the patient was diagnosed as brain stem infarction. He was treated by kinesitherapy (occupational and physical training), and swallowing disorder treatment. After 2 weeks of rehabilitation, his sitting balance reached grade 2; He could stand up from bed with one person’s assistance, but could not take a step. He experienced difficulty in lifting his feet and obvious spasticity of his right limbs. His MAS for left elbow flexion muscle, right hamstring, and right triceps surae was grade 2, whereas his left triceps surae was grade 1+. After taking Tizanidine (an oral antispasmodic drug) for about one month, with the dose gradually increasing from 6 mg/d to 12 mg/d. However, there was appeared some unexpected symptoms, such as dizziness and/or sleepiness [3].

Thus we decided to administer a local injection of megadose of BTX-A in the severe spasming limb muscles. The right upper flexor muscles and the right lower limb were injected with 250 IU and 450 IU, respectively. We chose 5 muscles as the targets for injection:

  1. The adduction muscle
  2. Hamstring muscles

  3. Triceps surae

  4. Posterior tibial muscle

  5. And/or flexor digitorum longus

We used surface electrodes to detect the most contracted and sensitive parts of the muscles, marked on the surface then inserted needle electrodes deeply into the muscle to search for the appropriate motor points. Drug preparation: 100 U BTX-A was diluted with 2 ml normal saline to a final concentration of 50 U/ml. 4-6 injection points for a large muscle and 1-2 for small muscles were selected; each point injected 0.5-1 ml (25-50 U) BTX-A. After 4-10 days, the tone of the injected muscles was decreased, and gradually the patient could also stand and take steps in a stable condition. Two weeks to 3 months after injection both the patient’s Modified Ashworth Scale (MAS) and independent functional walking ability improved significantly, except a short period of mild weakness of muscle strength, there is no adverse effect occurred.

Cases 2

A 48-year old male was admitted to ICU 2 months after multiple traumatic injuries during a traffic accident. PE: Clearminded and spoke fluently, but high-level intelligence was impaired, especially the memory and orientation ability, and both of his eyes had limited abduction, hypopsia of counting fingers at a 60 cm distance. The muscle forces for both the upper limbs were grade 4 (MMT), moving with slight fibrillation. The proximal muscle force of the left leg was grade 2, whereas the distal level was 0. The right lower limb proximal muscle force was grade 1 and the distal was grade 0, with increased muscle tone of MAS grade, for the bilateral quadriceps were level 3, and the bilateral adductors were level 2-3. Magnetic resonance imaging (MRI) showed changes after the traumatic brain injury, including hydrocephalus. Thus the final diagnosis of the patient was “Brain injury, Multiple fractured ribs, Left femur fracture, and Acute suppurative myelitis”.

After routine rehabilitation therapy for 3 months, the patient’s sitting balance was restored to level 2. He could stand up and sit down with assistance. He could stand but could not move with walking aid. The bilateral iliopsoas muscle forces were 2-3 level. He could walk 3-5 meters on flat ground with the use of bandages and support from two persons. His hips showed obvious bilateral adduction leading to an atypical scissors gait, which made knee flexion and sitting difficult. He was given a little dose of Tizanidine firstly, however, Tizanidine administration was rapidly terminated because of its adverse effects, such as lethargy, low blood pressure [3]. BTX-A injection was then administered to his bilateral adductor muscles and quadriceps femoris at a final dose of 350 U each. The dilution and injection methods were the same as those described in Case 1. After 3-7 days of injection, we evaluated the patients’ lower limb muscles spasm degree [4]. The MAS was improved significantly, and the grade of functional walking ability improved at 2 and 4 weeks respectively after the injection, lasting more than 3 months.

Discussion

BTX-A has been used to treat muscle tension disease for more than 50 years, and it has been widely applied by now [510]. At present, BTX-A can be made in several countries including China. The commercial name of Chinese BTX-A is HengLi, each vial contents 100 U. BTX blocks the physiological function of cholinergic nerve conduction, especially at the muscle-nerve joints, thus causing voluntary muscle relaxation. BTX-A is one of the most toxic substances in the world. However, after nearly 50 years of clinical application, the safety of BTX-A has been fully demonstrated [11]. A halflethal dose of mankind is 40 IU/kg, but with a maximum permissible dose of 600 U being the Chinese domestic expert consensus in 2010. As a result, repeated injections may cause immune complex diseases, so repeated BTX-A injection within 3 months is prohibited, but repeated injections have been reported in a short term within 1 week. Repeated injection in a short term is not well understood, and therefore, we do not advocate this approach.

We report two cases with muscle spasms after brain injury, who were treated by injecting BTX-A. Both the injection doses exceed the maximum dose of the Expert Consensus but were far from the median lethal dose. In both cases, no adverse reactions occurred, and the treatment helped achieving better clinical effects than the alternatives, similar to that reported in previous studies [1214]. Overdosage of BTX-A can be more efficacy and safe enough, therefore, in our further clinical study, according to the individual need and economic characteristics of the patient, we should reasonably and individually adjust the doses of BTX-A to achieve the best therapeutic effect and more beneficial to the patients’ self-care ability.

References

Source: Botulinum toxin type-A overdose for the treatment of spastic muscles in two patients with brain injuries

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[Abstract+References] Cognitive Behavior Therapy to Treat Sleep Disturbance and Fatigue After Traumatic Brain Injury: A Pilot Randomized Controlled Trial – Conference Paper

Abstract

Objective

To evaluate the efficacy of adapted cognitive behavioral therapy (CBT) for sleep disturbance and fatigue in individuals with traumatic brain injury (TBI).

Design

Parallel 2-group randomized controlled trial.

Setting

Outpatient therapy.

Participants

Adults (N=24) with history of TBI and clinically significant sleep and/or fatigue complaints were randomly allocated to an 8-session adapted CBT intervention or a treatment as usual (TAU) condition.

Interventions

Cognitive behavior therapy.

Main Outcome Measures

The primary outcome was the Pittsburgh Sleep Quality Index (PSQI) posttreatment and at 2-month follow-up. Secondary measures included the Insomnia Severity Index, Fatigue Severity Scale, Brief Fatigue Inventory (BFI), Epworth Sleepiness Scale, and Hospital Anxiety and Depression Scale.

Results

At follow-up, CBT recipients reported better sleep quality than those receiving TAU (PSQI mean difference, 4.85; 95% confidence interval [CI], 2.56–7.14). Daily fatigue levels were significantly reduced in the CBT group (BFI difference, 1.54; 95% CI, 0.66–2.42). Secondary improvements were significant for depression. Large within-group effect sizes were evident across measures (Hedges g=1.14–1.93), with maintenance of gains 2 months after therapy cessation.

Conclusions

Adapted CBT produced greater and sustained improvements in sleep, daily fatigue levels, and depression compared with TAU. These pilot findings suggest that CBT is a promising treatment for sleep disturbance and fatigue after TBI.

References

1Ponsford, J.L., Ziino, C., Parcell, D.L. et al, Fatigue and sleep disturbance following traumatic brain injury-their nature, causes, and potential treatments. J Head Trauma Rehabil. 2012;27:224–233.

Crossref

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2Mollayeva, T., Kendzerska, T., Mollayeva, S., Shapiro, C.M., Colantonio, A., Cassidy, J.D. A systematic review of fatigue in patients with traumatic brain injury: The course, predictors and consequences. Neurosci Biobehav Rev. 2014;47:684–716.

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3Ouellet, M.C., Morin, C.M. Fatigue following traumatic brain injury: frequency, characteristics, and associated factors. Rehabil Psychol. 2006;51:140–149.

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4Ouellet, M.C., Beaulieu-Bonneau, S., Morin, C.M. Sleep-wake disturbances after traumatic brain injury. Lancet Neurol. 2015;14:746–757.

Abstract

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[Abstract] Efficacy and safety of botulinum toxin type A for upper limb spasticity after stroke or traumatic brain injury: a systematic review with meta-analysis.

Abstract

INTRODUCTION:

Muscle spasticity is a positive symptom after stroke and traumatic brain injury. Botulinum toxin type A (BoNT-A) injection is widely used for treating post stroke and traumatic brain injury spasticity. This study aimed to evaluate efficacy and safety of BoNT-A for upper limb spasticity after stroke and traumatic brain injury and investigate reliability and conclusiveness of available evidence for BoNT-A intervention.

EVIDENCE ACQUISITION:

We searched electronic databases from inception to September 10 of 2016. Randomized controlled trials comparing the effectiveness between BoNT-A and placebo in stroke or traumatic brain injury adults with upper limb spasticity were included. Reliability and conclusiveness of the available evidence were examined with trial sequential analysis.

EVIDENCE SYNTHESIS:

From 489 citations identified, 22 studies were included, reporting results for 1804 participants. A statistically significant decrease of muscle tone was observed at each time point after BoNT-A injection compared to placebo (SMD at week 4=-0.98, 95% CI: -1.28 to -0.68; I2=66%, P=0.004; SMD at week 6=-0.85, 95% CI: -1.11 to -0.59, I2=1.2%, P=0.409; SMD at week 8=-0.87, 95% CI: -1.15 to -0.6, I2=0%, P=0.713; SMD at week 12=-0.67, 95% CI: -0.88 to -0.46, I2=0%, P=0.896; and SMD over week 12=-0.73, 95% CI: -1.21 to -0.24, I2=63.5%, P=0.065).Trial sequential analysis showed that as of year 2004 sufficient evidence had been accrued to show significant benefit of BoNT-A four weeks after injection over placebo control. BoNT-A treatment also significantly reduced Disability Assessment Scale Score than placebo at 4, 6 and 12-week follow-up period (WMD=-0.33, 95% CI: -0.63 to -0.03, I2=60%, P=0.114; WMD=-0.54, 95% CI: -0.74 to -0.33, I2= 0%, P=0.596 and WMD=-0.3, 95% CI: -0.45 to -0.14, I2=0%, P=0.426 respectively), and significantly increased patients’ global assessment score at week 4 and 6 after injection (SMD=0.56, 95% CI: 0.28 to 0.83; I2=0%, P=0.681 and SMD=1.11, 95% CI: 0.4 to 1.77; I2=72.8%, P=0.025 respectively). No statistical difference was observed in the frequency of adverse events between BoNT-A and placebo group (RR=1.36, 95% CI [0.82, 2.27]; I2=0%, P=0.619).

CONCLUSIONS:

As compared with placebo, BoNT-A injections have beneficial effects with improved muscle tone and well-tolerated treatment for patients with upper limb spasticity post stroke or traumatic brain injury.

Source: Efficacy and safety of botulinum toxin type A for upper limb spasticity after stroke or traumatic brain injury: a systematic review with meta-analy… – PubMed – NCBI

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[WEB SITE] Top 18 Apps for People with Brain Injuries

Note: This content was updated in February 2017. Some of the apps from the original post are still listed; however, we’ve found many more that can be extremely helpful…

We know what you’re thinking: don’t people with a traumatic brain injury have enough to relearn without training in new smart phone technology? Our answer: Yes and no. Yes, absolutely, which is why the apps we recommend are meant to complement existing therapies and programming. No, because the more frequently the mind is exercised, the greater the possibility of neuroplasticity rewiring the brain to be more functional in the future.

Technology today is working harder than ever to improve our lives. There are literally hundreds of apps for people with brain injuries and similar problems. We have selected these apps because they build on the day-to-day needs of an individual living with a TBI. We focused our research on these areas:
.         Social/Emotional
.         Functional
.         Cognitive
Specifically, these apps help clients work on the following: short-term memory loss, communication/socialization problems, anxiety, behavioral and organization issues.

Alarmed
Free with $1.99 Upgrade Available (iOS)
(Android Counterpart: Lists Alarmed!)
Alarmed augments short-term memory while the user is rebuilding his or her own. A productivity app for the masses, people with traumatic brain injuries can use Alarmed to create multiple reminders with unique, memorable tones for each task. Reminders can be customized with a “To Do” list and send multiple email reminders/updates. This app also comes with a timer to assist in programming.

Cozi Family Organizer
Free (iOS & Android)
Families can stay in sync on multiple platforms using this app that combines a shared calendar, shopping and “To Do” lists. With everyone on the same page, organizational skills are enhanced and frustration diminished.

EverNote 
Free (iOS & Android)
EverNote helps improve memory, organizational skills and even creativity by syncing ideas on multiple devices. The user can take notes, capture photos, create “To Do” lists and record voice reminders. The searchability function can be a tremendous boon for those with short-term memory loss.

Productive Habits and Daily Goals Tracker
Free with In-App Purchases (iOS)
(Android Counterpart: Habitizer) 
This app helps users develop positive habits in their lives by keeping them organized, tracking their progress and maintaining motivation. It allows users to set the habits they want to develop and receive reminders when tasks are to be completed. Users can color code these based on the priority or category of the habit. This app can also allow a therapist or caregiver to set priority levels for each task.

BrainHQ
Free with In-App Purchases (iOS)
(Android Counterpart: Luminosity)
Brain HQ tailors a training program for each persons’ unique mind. Therapeutic exercises are personalized based on performance and can help improve cognitive skills. Exercises are designed to improve attention, memory, people skills and navigation.

Brainscape – Smart Flashcards
Free to $9.99 with In-App Purchases (iOS & Android)
Pick a subject from geography to vocabulary-building and Brainscape has a set of smart digital flashcards. What makes these flashcards so smart? Besides being color-coded to aid recall, users are asked to indicate prior knowledge of the answers. Questions the user did not understand or answer correctly are repeated more frequently than those answered correctly.

Constant Therapy
Free for 30 Days (iOS & Android)
Constant Therapy is a speech therapy app for individuals who are looking to increase their cognitive abilities. This app is scientifically proven to improve speech, memory, cognition and comprehension skills. While this app can’t take the place of therapy, it is a great way to augment existing treatment by completing progressively challenging tasks right from your very own phone.

Spaced Retrieval TherAppy 
$3.99 (iOS)
(Android Counterpart: Spaced Retrieval)
Spaced Retrieval is a scientifically-proven way of improving recall of names, facts, the routines of several people and more. People with brain injuries can rehearse memory skills by recalling an answer over expanding intervals of time (1, 2, 4 or 8 minutes) that helps to cement the information in their memories. Please note: this app is not intended for use without therapy.

Answers: YesNo
$1.99 (iOS & Android)
For non-verbal clients, this app utilizes two large, color-coded buttons, green for “Yes” and red for “No”. When either button is pressed, the app vocalizes the client’s decision. This is a wonderful tool to help those with a brain injury or speech problem communicate without a struggle.

Audible
Free (iOS &Android)
Audible is for individuals who love a good book but are having difficulty reading, retaining information or who simply enjoy closing their eyes and having a good book read to them. With Audible, users do not have to give up their literary passions, they just have to listen.  This app is also compatible with Amazon, so books can be downloaded right from your account.

Clear Record Premium 
Price ranges from $.99 to $1.99 (iOS) depending on upgrades
(Android Counterpart: AndRecord)
This audio recording app allows the user to record conversations in practically any environment and play it back at the speed and volume of their choosing. Unlike many other voice-recording apps, Clear Record Premium filters out ambient sound to ensure pitch and clear voices.

Dragon Dictation
Free (iOS & Android)
Speak and this app will recognize the users voice and transcribe what they say into text messages, emails and even update social media. Dragon Dictation is a perfect mass media communication tool for anyone with a physical limitation.

Type ‘n Talk
Free (iOS)
(Android Counterpart: Type and Speak)
This app is incredibly useful for non-verbal individuals and other individuals who have difficulty with speech due to physical limitations. Type ‘n Talk allows the user to type what they need to say and their verbalized audio will play through whatever device is being used. This app also allows the user to copy text from websites and messages and provides a variety of languages.

Pocket Verbal Ability 
Free (iOS & Android) 
Users can increase their vocabulary with this user-friendly vocabulary app. Pocket Verbal Ability asks questions that will help prepare for job interviews, exams, and day-to-day life.

Social Skills 
$3.99 (iOS) 
(Android Counterpart: Talkingtiles)
This app includes the most common topics in the functional social skills system for people with brain injuries to model for appropriateness. Topics include the following: meeting/greeting people, taking responsibility, being polite, joining others in groups, apologizing/excusing self, following directions and handling criticism. Users watch a brief video of a person performing the correct behavior for the social situation and can then pattern their own behavior accordingly.

Breathe2Relax
Free (iOS & Android)
For anyone who could use a time out to relax, Breathe2Relax has been proven to help mood stabilization and control anger and anxiety. Users should simply indicate their level of stress and follow the audio instructions to breathe their way back to serenity. Essentially, this app provides on-site audio diaphragmatic breathing exercises.

WeFeel
Free (iOS & Android)
WeFeel is a mental health app that users can use to track their emotions and monitor how they change over time. This app can help manage emotions by allowing the user to visualize their anger, fear, stress, etc and then offer coping strategies. With a subscription, a counselor, therapist or caregiver will be able to monitor the users recorded emotions in real time from their own smart phone.

In Case of Emergency
$1.99 (iOS & Android)
This app allows people to store their medical information in a single location that is convenient for medical personnel in the event of any urgent situation. This app can also use to locate the nearest hospital.

All apps labeled iOS can be found at the Amazon.com: Apps & Games. Apps for Android can be found at either Google Play or the Amazon App Store for Android.

Since this is by no means an exhaustive list, we are always working to improve and add to it. We would love to hear from individuals with a traumatic brain injury and their physicians and caregivers about which apps they use.

Source: Top 18 Apps for People with Brain Injuries – LifeSkillsVillage.com

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