Posts Tagged Traumatic Brain Injuries

[ARTICLE] Transcranial direct current stimulation for the treatment of motor impairment following traumatic brain injury – Full Text

Abstract

After traumatic brain injury (TBI), motor impairment is less common than neurocognitive or behavioral problems. However, about 30% of TBI survivors have reported motor deficits limiting the activities of daily living or participation. After acute primary and secondary injuries, there are subsequent changes including increased GABA-mediated inhibition during the subacute stage and neuroplastic alterations that are adaptive or maladaptive during the chronic stage. Therefore, timely and appropriate neuromodulation by transcranial direct current stimulation (tDCS) may be beneficial to patients with TBI for neuroprotection or restoration of maladaptive changes.

Technologically, combination of imaging-based modelling or simultaneous brain signal monitoring with tDCS could result in greater individualized optimal targeting allowing a more favorable neuroplasticity after TBI. Moreover, a combination of task-oriented training using virtual reality with tDCS can be considered as a potent tele-rehabilitation tool in the home setting, increasing the dose of rehabilitation and neuromodulation, resulting in better motor recovery.

This review summarizes the pathophysiology and possible neuroplastic changes in TBI, as well as provides the general concepts and current evidence with respect to the applicability of tDCS in motor recovery. Through its endeavors, it aims to provide insights on further successful development and clinical application of tDCS in motor rehabilitation after TBI.

Background

Traumatic brain injury (TBI) is defined as “an alteration in brain function (loss of consciousness, post-traumatic amnesia, and neurologic deficits) or other evidence of brain pathology (visual, neuroradiologic, or laboratory confirmation of damage to the brain) caused by external force” [1]. The incidence and prevalence of TBI are substantial and increasing in both developing and developed countries. TBI in older age groups due to falling has been on the rise in recent years, becoming the prevalent condition in all age groups [23]. TBI causes broad spectrum of impairments, including cognitive, psychological, sensory or motor impairments [45], which may increase the socioeconomic burdens and reduce the quality of life [67]. Although motor impairment, such as limb weakness, gait disturbance, balance problem, dystonia or spasticity, is less common than neurocognitive or behavioral problems after TBI, about 30% of TBI survivors have reported motor deficits that severely limited activities of daily living or participation [8].

Motor impairment after TBI is caused by both focal and diffuse damages, making it difficult to determine the precise anatomo-clinical correlations [910]. According to previous clinical studies, recovery after TBI also seems worse than that after stroke, although the neuroplasticity after TBI may also play an important role for recovery [11]. Therefore, a single unimodal approach for motor recovery, including conventional rehabilitation, may be limiting, and hence, requiring a novel therapeutic modality to improve the outcome after TBI.

Transcranial direct current stimulation (tDCS) – one of the noninvasive brain stimulation (NIBS) methods – can increase or decrease the cortical excitability according to polarity (anodal vs. cathodal) and be used to modulate the synaptic plasticity to promote long-term functional recovery via long-term depression or potentiation [1213]. Recent clinical trials evaluating patients with stroke have reported the potential benefits of tDCS for motor recovery [14]. Neuroplastic changes after TBI and results from animal studies also suggest that tDCS could improve the motor deficit in TBI, although clinical trials using tDCS for motor recovery in TBI are currently lacking [14].

In this review, we will cover (1) the pathophysiology and possible neuroplastic changes in TBI; (2) physiology of tDCS; (3) current clinical evidence of tDCS in TBI for motor recovery; (4) general current concept of tDCS application for motor recovery; and (5) the future developments and perspectives of tDCS for motor recovery after TBI. Although the scope of motor recovery is wide, this review will focus primarily on the recovery of limb function, especially that of the upper limb. We expect that this review can provide insights on further successful development and clinical application of tDCS in motor rehabilitation after TBI.[…]

 

Continue —> Transcranial direct current stimulation for the treatment of motor impairment following traumatic brain injury | Journal of NeuroEngineering and Rehabilitation | Full Text

Fig. 3Schematic classification of personalized tDCS for motor recovery. Depending on electrode size, shape, and arrangement, tDCS can be broadly classified into a Conventional tDCS, b Customized Electrode tDCS, and c Distributed Array or High-Definition tDCS. Red color represents anodes and blue color represents cathodes

Fig. 5Merged system with tDCS and virtual reality. Patient with TBI can use this system in the hospital setting with the supervision of clinican (a) and can continue to use it at their home with tele-monitored system (b)

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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

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

 

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[Study] Transcranial Electrical Stimulation for mTBI (TES for mTBI)

Recruitment Status  : Recruiting

Study Description

Brief Summary:

Mild traumatic brain injury (mTBI) is a leading cause of sustained physical, cognitive, emotional, and behavioral deficits in OEF/OIF/OND Veterans and the general public. However, the underlying pathophysiology is not completely understood, and there are few effective treatments for post-concussive symptoms (PCS). In addition, there are substantial overlaps between PCS and post-traumatic stress disorder (PTSD) symptoms in mTBI. IASIS is among a class of passive neurofeedback treatments that combine low-intensity pulses for transcranial electrical stimulation (LIP-tES) with electroencephalography (EEG) monitoring. LIP-tES techniques have shown promising results in alleviating PCS individuals with TBI. However, the neural mechanisms underlying the effects of LIP-tES treatment in TBI are unknown, owing to the dearth of neuroimaging investigations of this therapeutic intervention. Conventional neuroimaging techniques such as MRI and CT have limited sensitivity in detecting physiological abnormalities caused by mTBI, or in assessing the efficacy of mTBI treatments. In acute and chronic phases, CT and MRI are typically negative even in mTBI patients with persistent PCS. In contrast, evidence is mounting in support of resting-state magnetoencephalography (rs-MEG) slow-wave source imaging (delta-band, 1-4 Hz) as a marker for neuronal abnormalities in mTBI. The primary goal of the present application is to use rs-MEG to identify the neural underpinnings of behavioral changes associated with IASIS treatment in Veterans with mTBI. Using a double-blind placebo controlled design, the investigators will study changes in abnormal MEG slow-waves before and after IASIS treatment (relative to a ‘sham’ treatment group) in Veterans with mTBI. In addition, the investigators will examine treatment-related changes in PCS, PTSD symptoms, neuropsychological test performances, and their association with changes in MEG slow-waves. The investigators for the first time will address a fundamental question about the mechanism of slow-waves in brain injury, namely whether slow-wave generation in wakefulness is merely a negative consequence of neuronal injury or if it is a signature of ongoing neuronal rearrangement and healing that occurs at the site of the injury. Specific Aim 1 will detect the loci of injury in Veterans with mTBI and assess the mechanisms underlying functional neuroimaging changes related to IASIS treatment using rs-MEG slow-wave source imaging. The investigators hypothesize that MEG slow-wave source imaging will show significantly higher sensitivity than conventional MRI in identifying the loci of injury on a single-subject basis. The investigators also hypothesize that in wakefulness, slow-wave generation is a signature of ongoing neural rearrangement / healing, rather than a negative consequence of neuronal injury. Furthermore, the investigators hypothesize IASIS will ultimately reduce abnormal MEG slow-wave generation in mTBI by the end of the treatment course, owing to the accomplishment of neural rearrangement / healing. Specific Aim 2 will examine treatment-related changes in PCS and PTSD symptoms in Veterans with mTBI. The investigators hypothesize that compared with the sham group, mTBI Veterans in the IASIS treatment group will show significantly greater decreases in PCS and PTSD symptoms between baseline and post-treatment assessments. Specific Aim 3 will study the relationship among IASIS treatment-related changes in rs-MEG slow-wave imaging, PCS, and neuropsychological measures in Veterans with mTBI. The investigators hypothesize that Reduced MEG slow-wave generation will correlate with reduced total PCS score, individual PCS scores (e.g., sleep disturbance, post-traumatic headache, photophobia, and memory problem symptoms), and improved neuropsychological exam scores between post-IASIS and baseline exams. The success of the proposed research will for the first time confirm that facilitation of slow-wave generation in wakefulness leads to significant therapeutic benefits in mTBI, including an ultimate reduction of abnormal slow-waves accompanied by an improvement in PCS and cognitive functioning.

MORE —>  Transcranial Electrical Stimulation for mTBI – No Study Results Posted – ClinicalTrials.gov

 

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