Posts Tagged Traumatic Brain Injury

[ARTICLE] Psychological Resilience Is Associated With Participation Outcomes Following Mild to Severe Traumatic Brain Injury – Full Text

Traumatic brain injury (TBI) causes physical and cognitive-behavioral impairments that reduce participation in employment, leisure, and social relationships. Demographic and injury-related factors account for a small proportion of variance in participation post-injury. Personal factors such as resilience may also impact outcomes. This study aimed to examine the association of resilience alongside demographic, injury-related, cognitive, emotional, and family factors with participation following TBI. It was hypothesized that resilience would make an independent contribution to participation outcomes after TBI. Participants included 245 individuals with mild-severe TBI [Mage = 44.41, SDage = 16.09; post traumatic amnesia (PTA) duration M 24.95 days, SD 45.99] who completed the Participation Assessment with Recombined Tools-Objective (PART-O), TBI Quality of Life Resilience scale, Family Assessment Device General Functioning Scale, Rey Auditory Verbal Learning Test, National Adult Reading Test, and Hospital Anxiety and Depression Scale an average 4.63 years post-injury (SD3.02, R 0.5–13). Multiple regression analyses were used to examine predictors of PART-O scores as the participation measure. Variables in the model accounted for a significant 38% of the variability in participation outcomes, F(13, 211) = 9.93, p < 0.05, R2 = 0.38, adjusted R2 = 0.34. Resilience was a significant predictor of higher participation, along with shorter PTA duration, more years since injury, higher education and IQ, and younger age. Mediation analyses revealed depression mediated the relationship between resilience and participation. As greater resilience may protect against depression and enhance participation this may be a focus of intervention.


Following traumatic brain injury (TBI), participation in employment, education, leisure, and relationships is often significantly reduced, leaving individuals substantially less integrated in their communities (14). As a result, many individuals spend increased time at home, straining family and other relationships (5). Given that TBI occurs commonly during young adulthood (6), participation deficits coincide with a critical period of development in which individuals are completing education, establishing a vocation, leaving home, and forming important lifelong relationships. Failure to attain these goals may profoundly impact their sense of self, mental health and general well-being. Reduced participation often extends beyond the acute recovery period and continues to be associated with poorer quality of life up to two decades after injury (7). Arguably participation in these life roles, including employment, education, leisure and relationships, represents one of the most important and objective indicators of injury outcomes.

Numerous variables have been associated with participation outcomes post-TBI, including injury-related and demographic variables as well as post-injury environmental and personal factors. Injury severity, cognitive difficulties, and limb injuries with related pain and impact on mood, affect an individual’s ability to engage socially and often present significant barriers to education and employment (816). Injury severity is a particularly well-researched predictor of participation outcomes, with duration of post traumatic amnesia (PTA) having the most robust association (1721). With respect to demographic factors, younger age, higher premorbid education level, higher premorbid IQ, and being employed prior to injury have all been associated with better participation outcomes (102229). Notably, older age at injury has been found to predict both worse participation overall as well as progressively worsening participation over time (10). Although gender does not appear to be directly associated with participation (30), it may have an indirect association, for example through mood and pre-injury education (14). Post-injury psychological functioning, particularly depression and anxiety, are also important predictors of participation outcomes (10123133). The impact of family functioning on participation is thought to be both direct, and through association with emotional well-being (3435).

Due to this broad range of factors influencing outcome, research has moved toward a multivariate approach to prediction of participation outcomes following TBI (24363738). These models contribute to a more comprehensive understanding of participation outcomes; however, the average amount of variance accounted for by predictive models is around 30% (21). This suggests there are additional predictive factors yet to be identified. One such factor that has increasingly gained scholarly recognition, due its positive association with quality of life and well-being outcomes among different clinical populations, is resilience.

Resilience has been conceptualized as a process of adaptation to adversity or the ability to bounce back after trauma or adversity. Resilience arguably influences the extent to which a person is able to resume important life roles after an injury. Resilience may impact participation outcomes directly through facilitating or promoting return to normal life or the development and achievement of new life goals (39), and indirectly through its effects on improved well-being, quality of life and psychological adjustment. Participating in employment, education, leisure, and relationships represent fundamental areas of participation. Resilience has been positively associated with physical and emotional well-being in individuals with cancer (40), Parkinson’s disease (41), diabetes (42), chronic spinal cord injury (43), multiple sclerosis, spina bifida, stroke, and posttraumatic stress disorder (4445). There has been less resilience research in TBI, with only one study to date examining the association between resilience and participation. Notably, it has been suggested that the study of resilience after TBI poses a distinct challenge, in that the skills characteristically associated with resilience are typically impaired after TBI (4547). For example, resilience requires emotional stability, a positive outlook, good problem-solving skills and social perception (47); however, TBI is commonly associated with impaired executive functioning (4849), irritability and aggression (5051), depression (3345), and difficulties with social perception (52).

The little research that has focused on resilience after TBI has been largely limited to patients with mild TBI, in whom no studies have examined impact on participation. In this group, greater resilience has been associated with less reporting of post-concussional and post-traumatic stress symptoms (5355), reduced fatigue, insomnia, stress, and depressive symptoms, as well as better quality of life (56). One study found that greater pre-injury resilience was significantly associated with greater post-concussion symptom severity 1 month post-injury (57), perhaps reflecting insufficient time for participants to “bounce back” (44), or overrating of pre-injury resilience levels, a phenomenon known as the “Good Old Days”(58).

Only three studies have examined resilience in individuals with moderate to severe TBI, of which one examined an association with participation. Marwitz et al. (39), conducted a large (n = 195) longitudinal study and found that resilience was significantly associated with participation over the first 12 months post-injury (39). Other studies have associated higher resilience in individuals with moderate to severe TBI with fewer depressive and anxiety symptoms, better emotional adjustment, use of task oriented coping and greater social support (4445). However, one of these studies used a sample of individuals who were actively seeking help with adjusting to changes post-injury, possibly biasing the sample toward those experiencing greater adjustment problems (45).

The aim of the present study was to examine the relative association of resilience, as well as demographic, injury-related, cognitive, emotional, and family factors with participation (productivity, social relations and leisure) following mild to severe TBI. To the best of our knowledge, this is the first study to examine the association between resilience and participation outcomes more than 12 months after mild to severe TBI. This critically extends previous research by examining the impact of resilience across the spectrum of TBI severity, from mild to severe, and how this association influences outcomes beyond the acute post-injury period. It was hypothesized that resilience would make an independent contribution to participation after TBI, in a model that would include demographic variables (gender, age, pre-morbid IQ, education, pre-injury employment), injury variables (injury severity, cognitive functioning, limb injury, time since injury) and post-injury personal and environmental factors (depression, anxiety, family support).[…]


Continue —> Frontiers | Psychological Resilience Is Associated With Participation Outcomes Following Mild to Severe Traumatic Brain Injury | Neurology


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[Abstract] Monitoring the injured brain



Traumatic brain injury can be defined as the most complex disease in the most complex organ. When an acute brain injury occurs, several pathophysiological cascades are triggered, leading to further exacerbation of the primary damage. A number of events potentially occurring after TBI can compromise the availability or utilization of energy substrates in the brain, ultimately leading to brain energy crisis. The frequent occurrence of secondary insults in the acute phase after TBI, such as intracranial hypertension, hypotension, hypoxia, hypercapnia, hyperthermia, seizures, can then increase cerebral damage, and adversely affect outcome. Neuromonitoring techniques provide clinicians and researchers with a mean to detect and reverse those processes that lead to this energy crisis, especially ischemic processes, and have become a critical component of modern neurocritical care. Which is the best way to monitoring the brain after an acute injury has been a matter of debate for decades. This review will discuss how monitoring the injured brain can reduce secondary brain damage and ameliorate outcome after acute brain injury.


Journal of Neurosurgical Sciences 2018 Apr 18 – Minerva Medica – Journals

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[Poster] Repetitive Transcranial Magnetic Stimulation (rTMS) application in cognitive deficits after Traumatic Brain Injury (TBI)/concussion

Objective: The objective of this study is to review current literature for the efficacy of Repetitive Transcranial Magnetic Stimulation (rTMS) treatment for cognitive deficits after Traumatic Brain Injury (TBI)/concussion.

Background: TBI is a major public health problem and can cause substantial disability. TBI can lead to Post Concussive Syndrome (PCS) which consists of neuro-motor, cognitive, behavioral/affective, and emotional symptoms. Cognitive deficits can significantly impact functionality. The outcome of neuropsychopharmacological treatment is limited, with risk for side effects. TMS is a form of non-invasive neuromodulation which is FDA-approved for treatment-resistant depression. However, there is limited understanding about its application in addressing cognitive deficits after TBI. We therefore sought to examine current research pertaining to the application of TMS in post-TBI cognitive deficits.

Methods: We searched the PubMed research database with the specific terms “TMS in cognitive deficits after TBI”, “rTMS” and “post concussive syndrome.” We assessed clinical trials where cognition was measured either as a primary or secondary variable. Case studies/reports were excluded.

Results: One non-controlled, pilot study was found that assessed cognition after TMS as a secondary variable in TBI. The aim of the study was to assess safety, tolerability and efficacy of repetitive TMS for treatment of PCS after mild TBI (mTBI). Patients who had sustained mTBI over three months prior and had a PCS Symptom Scale score of over 21 were selected. Repetitive TMS (rTMS) was used as the intervention with 20 sessions of rTMS using a figure-8 coil attached to MagPro stimulator. Cognitive symptoms were assessed using subjective self-report scales and objective tests for attention and speed of processing domains. Neuropsychological tests that were used include Trails A & B, Ruff’s 2 & 7 Automatic speed test, Stroop test, Language test for phonemic, and category fluency, Rey AVLT test. The study showed a reduction in overall severity of PCS symptoms but no significant changes on the cognitive symptoms questionnaire or on the majority of neuropsychological test scores.

Conclusion: Despite the limitation in this study with the lack of a control group, there appears to be a good signal for the clinical application of TMS for post-concussive syndrome after TBI/concussion. A more robust, large well-controlled study may be very reasonable approach in the future to evaluate efficacy of rTMS.


1. Koski L1, Kolivakis T, Yu C, Chen JK, Delaney S, Ptito A. Noninvasive brain stimulation for persistent postconcussion symptoms in mild traumatic brain injury. J Neurotrauma. 2015 Jan 1;32(1):38-44.

2. Bashir S1, Vernet M, Yoo WK, Mizrahi I, Theoret H, Pascual-Leone A. Changes in cortical plasticity after mild traumatic brain injury. Restor Neurol Neurosci. 2012;30(4):277-82.

3. Demirtas-Tatlidede A1, Vahabzadeh-Hagh AM, Bernabeu M, Tormos JM, Pascual-Leone A.Noninvasive brain stimulation in traumatic brain injury. J Head Trauma Rehabil. 2012 Jul-Aug;27(4):274-92.

4. Neville IS, Hayashi CY, El Hajj SA, Zaninotto AL, Sabino JP, Sousa LM Jr, Nagumo MM, Brunoni AR, Shieh BD, Amorim RL, Teixeira MJ, Paiva WS. Repetitive Transcranial Magnetic Stimulation (rTMS) for the cognitive rehabilitation of traumatic brain injury (TBI) victims: study protocol for a randomized controlled trial. Trials. 2015 Oct 5;16:440.

via Repetitive Transcranial Magnetic Stimulation (rTMS) application in cognitive deficits after Traumatic Brain Injury (TBI)/concussion – Brain Stimulation: Basic, Translational, and Clinical Research in Neuromodulation

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[ARTICLE] Pituitary dysfunction following traumatic brain injury: clinical perspectives – Full Text


Traumatic brain injury (TBI) is a well recognized public health problem worldwide. TBI has previously been considered as a rare cause of hypopituitarism, but an increased prevalence of neuroendocrine dysfunction in patients with TBI has been reported during the last 15 years in most of the retrospective and prospective studies. Based on data in the current literature, approximately 15%–20% of TBI patients develop chronic hypopituitarism, which clearly suggests that TBI-induced hypopituitarism is frequent in contrast with previous assumptions. This review summarizes the current data on TBI-induced hypopituitarism and briefly discusses some clinical perspectives on post-traumatic anterior pituitary hormone deficiency.


Traumatic brain injury (TBI) could be defined as a change in brain function or other evidence of brain pathology caused by external forces,1 and is a well recognized public health problem worldwide. A substantial number of people with TBI are seen in emergency departments; the great majority, approximately 235,000 each year, are hospitalized because of non-fatal TBI and nearly 50,000 die according to reports from the USA. Further, the overall annual incidence of TBI in the USA has been reported to be 506 per 100,000 population.2 The severity ratio of hospitalized TBI patients was reported to be approximately 22:1.5:1 for mild to moderate to severe cases, respectively.3 Thus, there is no doubt that TBI is one of the most common causes of mortality and long-term disability among young adults. The main causes of TBI are road traffic accidents (the leading cause, accounting for 50% of all cases), falls, violence-related incidents, sports-related head trauma (hockey, soccer, football), combative sports (boxing and kickboxing) characterized by chronic repetitive head trauma, and war-related accidents, including blast injuries.47

Although TBI has previously been considered as a rare cause of hypopituitarism, an increased prevalence of neuroendocrine dysfunction in patients with TBI has been reported during the last 15 years in most of the retrospective and prospective studies.818 This review summarizes the current data on TBI-induced hypopituitarism and briefly discusses some clinical perspectives on post-traumatic anterior pituitary hormone deficiency.[…]


Continue —> Pituitary dysfunction following traumatic brain injury: clinical perspectives

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[Editorial] Investigating Brain Activity After Acquired and Traumatic Brain Injury: Applications of Functional MRI

  • 1Stroke, Kessler Foundation, West Orange, NJ, United States
  • 2Neuropsychology and Neuroscience, Kessler Foundation, West Orange, NJ, United States
  • 3Traumatic Brain Injury, Kessler Foundation, West Orange, NJ, United States

Editorial on the Research Topic

Investigating Brain Activity After Acquired and Traumatic Brain Injury: Applications of Functional MRI

Every year, approximately 795,000 people in the United States are affected by stroke and 2.8 million lives are impacted by traumatic brain injury (TBI) (1). Stroke and TBI are also major causes of serious long-term disability, reducing mobility, and impacting thinking, memory, sensation, and emotional functioning. Neuroscience holds great promise in addressing the needs of persons with a history of stroke or TBI by improving the current understanding of brain injury and recovery mechanisms. This is the first step in working to inform and improve the available treatments.

While a great many functional neuroimaging methods exist for studying the healthy brain, such methods have not received widespread acceptance in characterizing patient groups. Several methodological barriers may explain why. First, patient populations can be diverse in terms of injury location and stages of recovery. Accurate measurement and interpretation of functional neuroimaging signal in the damaged brain can also pose a challenge, because stroke and TBI can dramatically alter cerebral blood flow, even in areas that are not affected by a structural lesion (23). Finally, correct interpretation of findings in light of impaired and/or changing behavioral function depends on careful experimental design and precise a priorioperational definitions of the anticipated effects.

Despite these challenges, or, perhaps, because of them, functional neuroimaging is a promising area of investigation in TBI and stroke. This Research Topic is a collection of original research and review articles focused on functional neuroimaging in persons with TBI and stroke. Below, we highlight a few of the most notable findings and ideas from this collection of articles. Readers are encouraged to access the full text articles for more details.

In one of the two review articles, Medaglia provides an overview of fMRI methodology, analyses, and the caveats of applying these analyses to the injured brain. This includes methods, such as seed-based and voxel-based functional connectivity, effective connectivity, including psychophysiological interactions, causal connectivity, and graph analyses. Medaglia discusses the concept of functional re-organization. The term is sometimes used to describe a change in the magnitude of activation or of functional connectivity. It is also used to refer to a re-allocation of function to new brain areas following injury. Medaglia suggests that to improve clarity a precise description of the effect should be provided. Formal tests of re-organization should include a search for areas with activity profile closely resembling that of a damaged area, and with corresponding evidence of recovered behavioral function. Distinguishing different innate recovery mechanisms is especially important in intervention studies, because failing to understand which process may be at work when introducing an intervention, may lead to inadvertent interference with endogenous repair mechanisms.

Nair et al. studied brain activation in acute stroke and healthy older controls participants during a covert verbal fluency task. They controlled for the blood oxygen level dependent (BOLD) response variability across participants using resting state fluctuation amplitude (RSFA) (4). RSFA calibration is thought to eliminate any inter-subject variability due to vascular factors and retain any differences due to neuronal activation factors. They found that after scaling, the BOLD response differences between stroke patients and healthy controls were eliminated. This finding suggests that some of the group differences were due to vascular variables. Additionally, some fine-tuning may be required when scaling with RSFA, perhaps scaling by brain region, rather than across the whole brain.

Bernier et al. applied graph theory to a data set of healthy and TBI subjects with moderate/severe TBI. Their aim was to determine if loss of network differentiation accounts for changes in brain connectivity, specifically hyperconnectivity. This hypothesis was examined within the default mode (DMN) and the task positive network. Supporting other results in the field, they observed hyperconnectivity within the DMN and task positive networks. DMN hyperconnectivity was found to be associated with higher scores on the standardized working memory measure. Thus, the work of these authors demonstrates how fMRI and connectivity analyses can inform the cognitive profile observed following TBI.

The second review in the Research Topics explores a common deficit in TBI. Namely, cognitive control, an executive function that is generally necessary for switching between habitual and goal-directed behavior. In his review, Scheibel talks about functional neuroimaging studies of cognitive control in mild TBI (mTBI). The review draws attention to how the fMRI findings are mixed, with reports of decreased as well as increased brain activation in mTBI, and urges for future studies to aim at recruiting more homogenous samples, as the mixed findings might be explained by the presence of comorbidies in TBI samples.

The original research article by Saleh et al. explored how different approaches to rehabilitation of hand function after stroke can alter brain activity across the sensorimotor brain networks and demonstrates network re-organization discussed in the Medaglia review. Both treatment approaches tested in the study improved hand function. However, only the robot-assisted virtual reality group showed reduction of activity and re-lateralization of activation to ipsilesional cortex, a pattern associated with better arm function in this study and with positive recovery in other studies (5).

A contribution by Möller et al. used arterial spin labeling (ASL) fMRI to examine fatigue in mTBI during psychomotor vigilance task performance. The mTBI participants showed different patterns of brain activation compared to healthy controls, in addition to higher self-reported fatigue and reductions in performance as the task progressed (fatigability). Together with the self-reported fatigue ratings and task performance, the ASL results suggested the engagement of disparate functional networks compared in mTBI.

fMRI research in stroke and TBI poses a unique set of challenges to researchers. The articles assembled in this Research Topic address some of these challenges. Using methods designed to work in patients with brain lesions, using appropriate controls, and applying network neuroscience tools are a few of the promising solutions. This topic is an important frontier in neuroscience research today offering tangible benefits for public health and is a potential area of growth in the coming years


1. Centers for Disease Control and Prevention (CDC). U. Centers for Disease con [WWW Document]. (2018). Available from: (Accessed: February 22, 2018).

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2. Brumm KP, Perthen JE, Liu TT, Haist F, Ayalon L, Love T. An arterial spin labeling investigation of cerebral blood flow deficits in chronic stroke survivors. Neuroimage (2010) 51:995–1005. doi:10.1016/j.neuroimage.2010.03.008

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3. Hillis AE. Magnetic resonance perfusion imaging in the study of language. Brain Lang (2007) 102:165–75. doi:10.1016/j.bandl.2006.04.016

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4. Kannurpatti SS, Motes MA, Rypma B, Biswal BB. Increasing measurement accuracy of age-related BOLD signal change: minimizing vascular contributions by resting-state-fluctuation-of-amplitude scaling. Hum Brain Mapp (2011) 32:1125–40. doi:10.1002/hbm.21097

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5. Cramer SC. Repairing the human brain after stroke: I. Mechanisms of spontaneous recovery. Ann Neurol (2008) 63:272–87. doi:10.1002/ana.21393

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[PERSPECTIVE ARTICLE] Virtual Reality for Traumatic Brain Injury – Full Text

In this perspective, we discuss the potential of virtual reality (VR) in the assessment and rehabilitation of traumatic brain injury, a silent epidemic of extremely high burden and no pharmacological therapy available. VR, endorsed by the mobile and gaming industries, is now available in more usable and cheaper tools allowing its therapeutic engagement both at the bedside and during the daily life at chronic stages after injury with terrific potential for a longitudinal disease modifying effect.


The World Health Organization estimates that traumatic brain injury (TBI) is and will remain the most important cause of neurodisability in the coming years (1). The search for neuroprotective therapies for severe TBI has been extensive but unfruitful over the last few decades, testified by more than 30 failed clinical trials, and we still have no specific neuroprotective therapy, that is, effective in clinical TBI. The burden of mortality and residual disability calls for new approaches to promote recovery of function of TBI patients in the acute and chronic phase (23).

Classically described as a sudden event with short-term consequences, TBI induces dynamic pathological cascades that may persist for months or years after injury with a major impact on outcome (45). Among dynamic mechanisms, the neuroinflammatory response and the accumulation of aberrant proteins may have a critical role in establishing a neuropathological link between acute mechanical injury and late neurodegeneration (67). The close association between post-TBI neurological changes, persistent neuroinflammation, and late neuropathology highlights the fact that the window of opportunity for therapeutic intervention may be much wider than previously thought and that long-term treatment encompassing the acute and chronic phase should be tested to effectively interfere with this complex condition.

Importantly, next to the harmful processes, TBI also induces a neuro-restorative response that includes angiogenesis, neurogenesis, and brain plasticity (89). These spontaneous regenerative mechanisms are short-lived and too weak to counteract damage progression but they could point the way to new therapeutic options if appropriately boosted and amplified. Physical and cognitive exercise increase repair and brain plasticity after injury in experimental models and patients (1011). Rehabilitative programs to provide inputs/stimuli to specific sensory or motor neural circuits, could in principle start very early on, and be finely tuned over time to account for the type and degree of injury and the level of motor and cognitive disability.

Virtual Reality (VR) for Rehabilitation after TBI

Cognitive and physical rehabilitation programs are fundamental instruments to improve the clinical outcome of TBI patients optimizing the activities, function, performance, productivity, participation, and quality of life (12). They are based on restitutional, compensatory, and adaptive strategies and vary in relation to the patient potential and disability degree (212).

Traumatic brain injury encompasses heterogeneous etiology, as well as structural and molecular patterns of injury dictating different prognostic features and potential responses to rehabilitative therapy. Experimental studies indicate that depending on the degree of cognitive and sensorimotor impairment exercise may improve outcome with different window of opportunity, however, evidence supporting the optimal timing, type, and intensity of rehabilitative interventions in patients are scarce (1213). For example, rehabilitation is often delayed in patients with severe TBI until their discharge from the intensive care unit, or adopted in the most severe cases with only minimal goals aimed at limiting spasticity (14). Importantly, cognitive rehabilitation in the sub-acute stage of TBI is rarely considered. For these reasons, the use of innovative techniques is advocated to assess the TBI-related deficits and to develop and evaluate new rehabilitative interventions (12).

An emerging technology, VR, represents a new tool for this purpose and might provide TBI care teams with new neuro-restorative strategies readily available at the bedside. Since the late 1980s, this term has been used to describe a 3D synthetic environment created by computer graphics, where the user has the feeling of being inside (15). VR can be described as “an advanced form of human-computer interface that allows the user to interact with and become immersed in a computer-generated environment in a naturalistic fashion” (16). For its flexibility, sense of presence (i.e., the feeling of “being there”) and emotional engagement, VR has been tested in motor and cognitive rehabilitation, with good results. In stroke patients, the number of VR programs is rapidly increasing with compelling data showing an improvement in recovery of motor function and daily living activities (17).

Data on the effects of cognitive function and quality of life are more limited. As underlined by two recent systematic reviews (1819), VR allows a level of engagement and cognitive involvement, higher than the one provided by memory and imagination, but is more controlled and can be more easily measured than that offered by direct “real” experience. Its multisensory stimulation means VR can be considered an enriched environment that can offer functional and ecological real-world demands (e.g., finding objects, assembling things, and buying stuff) that may improve brain plasticity and regenerative processes (2022).

There are several examples in the literature where VR has been successfully used both as assessment instrument and as therapeutic intervention. As assessment tool, VR has been used to detect visual-vestibular deficits in adults after concussion and mild TBI (2324). Wright WG et al., developed a Virtual Environment TBI Screen that allows subjects to explore a digitalized setting (i.e., outdoor Greek temple with columns, different kind of floor materials, etc.) performing postural tasks while the system collects data to detect visual-vestibular deficits. Besnard et al. (25) created a virtual kitchen to assess daily-life activity and evaluate executive dysfunctions in subjects with severe TBI. Robitaille et al. (26) developed a VR avatar interaction platform to assess residual executive functions in subjects with mild TBI. The platform can capture real-time subject’s movements translating them in to a virtual body, that is, therefore placed in a simulated environment (i.e., a village). The user is then allowed to explore the simulate surroundings which comprise different navigational obstacles to overcome. Similar approaches have been used by other authors, whereas simplified settings (i.e., 3D virtual corridor that the subject can explored with a joystick) have been proved useful to assess subclinical cognitive abnormalities in asymptomatic subjects that suffered a concussion (27).

As therapeutic instrument, Dahdah et al. (28) demonstrated that immersive VR intervention can be used as an effective neuro-rehabilitative tool to enhance executive functions and information processing in the sub-acute period, providing evidence of positive effects of a virtual Stroop task over traditional non-VR-based protocol. VR as therapeutic instrument has also been used for attention training in severe TBI with positive results in the early recovery stages (29) with a specific “augmented” task in which virtual and haptic feedbacks were used in a target-reaching exercise to enhance sustained attention. Finally, virtual protocols generated upon commercial available game solutions have been effective in addressing and treating balance deficits (30).

All these works suggest that VR could be useful as assessment instrument and in the rehabilitation of TBI, nonetheless a delineated pattern seems to emerge. VR assessment protocols appear to be primarily implemented for mild TBI, which induce subtle residual deficits hard to detect with traditional instruments (23). Conversely, VR treatment protocols for cognitive rehabilitation are used transversely from mild to severe conditions, although effectiveness of these kinds of interventions needs to be further explored (31).[…]


Continue —>  Frontiers | Virtual Reality for Traumatic Brain Injury | Neurology

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[Abstract] Depression in the First Year after Traumatic Brain Injury


The aims of this study were to document the frequency of major and minor depressive episodes in the first year after traumatic brain injury (TBI), taking into account TBI severity and pre-morbid history of major depression, and to describe trajectories of depressive episodes. Participants were 227 adults who were hospitalized post-TBI (76% male; mean age = 41 years; 50% mild, 33% moderate, and 17% severe TBI). Major and minor depressive episodes were assessed with the Mini International Neuropsychiatric Interview at three time points (4, 8, and 12 months after TBI). Overall, 29% of participants had a major depressive episode in at least one of the three assessments, with fairly stable rates across assessments. Participants with mild TBI were more likely than those with moderate/severe TBI to be diagnosed with major depression, as were individuals with a positive pre-morbid history of depression compared to those without such history. In addition, 13% of participants had a minor depressive episode in at least one of the three assessments. Rates of minor depression significantly decreased from 4 to 8–12 months post-injury. Results also revealed a wide variety of trajectories of depressive episodes across assessments. Of note, 52% of major depression cases still fulfilled diagnostic criteria 4 months later, whereas 38% of minor depression cases deteriorated to major depression at the following assessment. These findings suggest that depression is highly prevalent after TBI, and monitoring of patients with subthreshold depressive symptoms is warranted in order to prevent the development of full-blown major depressive episodes.


via Depression in the First Year after Traumatic Brain Injury | Journal of Neurotrauma

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[Abstract] Cognition, Health-Related Quality of Life, and Depression Ten Years after Moderate to Severe Traumatic Brain Injury: A Prospective Cohort Study

The aim of this study was to evaluate cognitive function 10 years after moderate-severe traumatic brain injury (TBI) and to investigate the associations among cognitive function, depression, and health-related quality of life (HRQoL). In this prospective cohort study, with measurements at 3, 6, 12, 18, 24, 36, and 120 months post-TBI, patients 18–67 years of age (n = 113) with moderate-severe TBI were recruited. Main outcome measures were depression (Center for Epidemiologic Studies-Depression Scale [CES-D]), subjective cognitive functioning (Cognitive Failure Questionnaire [CFQ]), objective cognitive functioning, and HRQoL (Medical Outcomes Study 36-Item Short Form Health Survey [SF-36]). Fifty of the initial 113 patients completed the 10 year follow-up. Twenty percent showed symptoms of depression (CES-D ≥ 16). These patients had more psychiatric symptoms at hospital discharge (p = 0.048) and were more often referred to rehabilitation or nursing homes (p = 0.015) than non-depressed patients. Further, they also had significantly lower scores in six of the eight subdomains of the SF-36. The non-depressed patients had equivalent scores to those of the Dutch norm-population on all subdomains of the SF-36. Cognitive problems at hospital discharge were related with worse cognitive outcome 10 years post-TBI, but not with depression or HRQoL. Ten years after moderate-severe TBI, only weak associations (p < 0.05) between depression scores and two objective cognitive functioning scores were found. However, there were moderate associations (p < 0.01) among depression scores, HRQoL, and subjective cognitive functioning. Therefore, signaling and treatment of depressive symptoms after moderate-severe TBI may be of major importance for optimizing HRQoL in the long term. We did not find strong evidence for associations between depression and objective cognitive functioning in the long term post-TBI. Disease awareness and selective dropping out may play a role in long-term follow-up studies in moderate-severe TBI. More long-term research is needed in this field.


via Cognition, Health-Related Quality of Life, and Depression Ten Years after Moderate to Severe Traumatic Brain Injury: A Prospective Cohort Study | Journal of Neurotrauma

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[ARTICLE] Advanced Robotic Therapy Integrated Centers (ARTIC): an international collaboration facilitating the application of rehabilitation technologies – Full Text



The application of rehabilitation robots has grown during the last decade. While meta-analyses have shown beneficial effects of robotic interventions for some patient groups, the evidence is less in others. We established the Advanced Robotic Therapy Integrated Centers (ARTIC) network with the goal of advancing the science and clinical practice of rehabilitation robotics. The investigators hope to exploit variations in practice to learn about current clinical application and outcomes. The aim of this paper is to introduce the ARTIC network to the clinical and research community, present the initial data set and its characteristics and compare the outcome data collected so far with data from prior studies.


ARTIC is a pragmatic observational study of clinical care. The database includes patients with various neurological and gait deficits who used the driven gait orthosis Lokomat® as part of their treatment. Patient characteristics, diagnosis-specific information, and indicators of impairment severity are collected. Core clinical assessments include the 10-Meter Walk Test and the Goal Attainment Scaling. Data from each Lokomat® training session are automatically collected.


At time of analysis, the database contained data collected from 595 patients (cerebral palsy: n = 208; stroke: n = 129; spinal cord injury: n = 93; traumatic brain injury: n = 39; and various other diagnoses: n = 126). At onset, average walking speeds were slow. The training intensity increased from the first to the final therapy session and most patients achieved their goals.


The characteristics of the patients matched epidemiological data for the target populations. When patient characteristics differed from epidemiological data, this was mainly due to the selection criteria used to assess eligibility for Lokomat® training. While patients included in randomized controlled interventional trials have to fulfill many inclusion and exclusion criteria, the only selection criteria applying to patients in the ARTIC database are those required for use of the Lokomat®. We suggest that the ARTIC network offers an opportunity to investigate the clinical application and effectiveness of rehabilitation technologies for various diagnoses. Due to the standardization of assessments and the use of a common technology, this network could serve as a basis for researchers interested in specific interventional studies expanding beyond the Lokomat®.


The number of technological devices that therapists can utilize to treat people with neurological impairments has grown substantially during the last decade. Alongside this growth in clinical use, research involving robotic therapy has grown rapidly. A search in Pubmed with the terms “robot” OR “robotic*” AND “rehabilitation” revealed 2225 hits (March 2017) with research markedly increasing after 2010. Despite this increase in research activity and clinical use, the effectiveness of robot-assisted interventions in neurorehabilitation is still in debate. While in some patient populations, for example adults with stroke, meta-analyses have shown that robotic interventions for the lower and upper extremity can be beneficial [12], current evidence is much less convincing in other patient groups, such as spinal cord injury (SCI), traumatic brain injury (TBI), multiple sclerosis (MS) and cerebral palsy (CP).

When comparing the effectiveness of robot-assisted gait training (RAGT) to conventional interventions of similar dosage in adult patients after SCI, it appears that neither intervention is superior [34]. In other populations, such as MS, a small number of pilot studies have been conducted, and a review [5] concluded that the evidence for the effectiveness remained inconclusive. In adult patients with TBI, to our knowledge, there is only one randomized controlled trial that investigated the effectiveness of RAGT [6]. While RAGT improved gait symmetry compared to manually assisted body-weight supported treadmill training, improvements in other gait parameters were not different between the interventions. In children with CP, the body of evidence is similarly small, as only two randomized trials were found [78]. To the authors’ knowledge, there are no randomized controlled trials in children with other diagnoses. Studies comparing effectiveness between different patient groups are lacking.

One important factor leading to the lack of conclusive research is the relatively small number of available centers and participating patients and consequently the small statistical power of attempted studies. Multicenter collaborations are needed to achieve adequate number of participants. Several of the limitations in the evidence of the application of RAGT arise from patient selection criteria and use of different, poorly described and/or low-dosed training protocols. For example, when systematically reviewing the literature in children, we found no paper describing a training protocol on how to apply a robot for rehabilitation of gait [9]. Most of the systematic reviews mentioned that it is extremely difficult to pool results from studies due to the large variability in treatment duration and frequency, contents of the training and inclusion criteria of the patients. For children with CP, an expert team was created to formulate goals, inclusion criteria, training parameters and recommendations on including RAGT in the clinical setting, to assist therapists who train children with CP with the Lokomat® (Hocoma AG, Volketswil, Switzerland) [9]. Such information could be used as a first step in defining training protocols, but this information is missing for most other patient groups.

While randomized controlled trials are usually considered the “gold standard” in building solid evidence in the field of medicine, it is often difficult for rehabilitation specialists working in the clinical environment to interpret the findings with respect to the population of patients they treat on a daily basis. Randomized controlled trials require a specialized team, a controlled setting and a strict selection of patients according to well defined inclusion and exclusion criteria. These criteria often select individuals most likely to benefit based on specific parameters and lack of co-morbidities. These narrow criteria may impact the ecological validity, as results only apply to a minority of patients. This was recently investigated by Dörenkamp et al. [10] who reported that the majority of patients in primary care (40% at the age of 50 years and at least two-thirds of the octogenarian population [11]) simultaneously suffered from multiple medical problems. Further, improvements in function might be less comparable to results described in randomized controlled trials and the treatment regimens used may not be applicable to patients with multiple comorbidities.

To overcome these issues, we established the Advanced Robotic Therapy Integrated Centers (ARTIC) network to collect data from patients using RAGT in a wide variety of clinical settings. ARTIC hopes to develop guidelines for usage as well as to answer scientific questions concerning the use of RAGT. While the ARTIC network includes a general patient population, other research networks focus on a specific disorder or diagnostic group (see, for example [1213]). ARTIC focuses on a common technological intervention – currently the driven gait orthosis Lokomat® – and aims to gather evidence for the efficient and effective use of robotic therapy. Variation in practice among ARTIC members together with collection of common data and outcome measurements will enable the group to draw strong, generalizable conclusions. Further goals include establishing standardized treatment protocols and increasing medical and governmental acceptance of robotic therapy. The aims of this paper are to introduce the ARTIC network to the clinical and research community, present initial data on the characteristics of included patients and compare these to those known from existing epidemiological data and interventional studies.[…]


Continue —> Advanced Robotic Therapy Integrated Centers (ARTIC): an international collaboration facilitating the application of rehabilitation technologies | Journal of NeuroEngineering and Rehabilitation | Full Text

Fig. 1 Lokomat® system (of different generations) with (a) adult leg orthoses and (b) pediatric leg orthoses. Patients walk on a treadmill belt, are weight supported, and the exoskeleton device guides the legs through a physiological walking pattern

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[Abstract] Longitudinal Recovery of Executive Control Functions After Moderate-Severe Traumatic Brain Injury: Examining Trajectories of Variability and Ex-Gaussian Parameters

Background. Executive control deficits are deleterious and enduring consequences of moderate-severe traumatic brain injury (TBI) that disrupt everyday functioning. Clinically, such impairments can manifest as behavioural inconsistency, measurable experimentally by the degree of variability across trials of a reaction time (RT) task (also known as intraindividual variability [IIV]). Growing research on cognition after TBI points to cognitive deterioration in the chronic stages postinjury. Objective. To examine the longitudinal recovery of RT characteristics (IIV and more detailed ex-Gaussian components, as well as the number of impulsively quick responses) following moderate-severe TBI. Methods. Seventy moderate-severe TBI patients were assessed at 2, 5, 12, and 24+ months postinjury on a go/no-go RT task. RT indices (ex-Gaussian parameters mu and sigma [mean and variability of the normal distribution component], and tau [extremely slow responses]; mean, intraindividual coefficient of variation [ICV], and intraindividual standard deviation [ISD]) were analyzed with repeated-measures multivariate analysis of variance. Results. ICV, ISD, and ex-Gaussian tau significantly decreased (ie, improved) over time in the first year of injury, but worsened from 1 to 2+ years, as did the frequency of extremely fast responses. These quadratic patterns were accentuated by age and shown primarily in tau (extremely slow) and extremely fast (impulsive) responses. Conclusions. The pattern of early recovery followed by decline in executive control function is consistent with growing evidence that moderate-severe TBI is a progressive and degenerative disorder. Given the responsiveness to treatment of executive control deficits, elucidating the trajectory and underpinnings of inconsistent behavioral responding may reveal novel prognostic and clinical management opportunities.

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via Longitudinal Recovery of Executive Control Functions After Moderate-Severe Traumatic Brain Injury: Examining Trajectories of Variability and Ex-Gaussian Parameters – Brandon P. Vasquez, Jennifer C. Tomaszczyk, Bhanu Sharma, Brenda Colella, Robin E. A. Green, 2018

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