Posts Tagged Traumatic Brain Injury
[Abstract] Cognitive Behavioral Therapy for Sleep Disturbance and Fatigue Following Acquired Brain Injury
Predictors of Treatment Response
To identify factors associated with treatment response to cognitive behavioral therapy for sleep disturbance and fatigue (CBT-SF) after acquired brain injury (ABI).
Thirty participants with a traumatic brain injury or stroke randomized to receive CBT-SF in a parent randomized controlled trial.
Participants took part in a parallel-groups, parent randomized controlled trial with blinded outcome assessment, comparing an 8-week CBT-SF program with an attentionally equivalent health education control. They were assessed at baseline, post-treatment, 2 months post-treatment, and 4 months post-treatment. The study was completed either face-to-face or via telehealth (videoconferencing). Following this trial, a secondary analysis of variables associated with treatment response to CBT-SF was conducted, including: demographic variables; injury-related variables; neuropsychological characteristics; pretreatment sleep disturbance, fatigue, depression, anxiety and pain; and mode of treatment delivery (face-to-face or telehealth).
Pittsburgh Sleep Quality Index (PSQI) and Fatigue Severity Scale (FSS).
Greater treatment response to CBT-SF at 4-month follow-up was associated with higher baseline sleep and fatigue symptoms. Reductions in fatigue on the FSS were also related to injury mechanism, where those with a traumatic brain injury had a more rapid and short-lasting improvement in fatigue, compared with those with stroke, who had a delayed but longer-term reduction in fatigue. Mode of treatment delivery did not significantly impact CBT-SF outcomes.
Our findings highlight potential differences between fatigue trajectories in traumatic brain injury and stroke, and also provide preliminary support for the equivalence of face-to-face and telehealth delivery of CBT-SF in individuals with ABI.
[Abstract] Over-ground robotic lower limb exoskeleton in neurological gait rehabilitation: User experiences and effects on walking ability
BACKGROUND: Over-ground robotic lower limb exoskeletons are safe and feasible in rehabilitation with individuals with spinal cord injury (SCI) and stroke. Information about effects on stroke rehabilitees is scarce and descriptions of learning process and user experience is lacking.
OBJECTIVE: The objectives of this study were to describe how rehabilitees learn exoskeleton use, to study effects of exoskeleton assisted walking (EAW) training, and to study rehabilitees’ user experiences.
METHODS: One-group pre-test post-test pre-experimental study involved five rehabilitees with stroke or traumatic brain injury (TBI). Participants in chronic phase underwent twice a week an 8-week training intervention with Indego exoskeleton. Process of learning to walk and the level of assistance were documented. Outcome measurements were conducted with 6-minute and 10-meter walk tests (6 MWT, 10 mWT). User experience was assessed with a satisfaction questionnaire.
RESULTS: Rehabilitees learnt to walk using the exoskeleton with the assistance from 2–3 therapists within two sessions and progressed individually. Three participants improved their results in 10 mWT, four in 6 MWT. The rehabilitees felt comfortable and safe when using and exercising with the device.
CONCLUSION: Indego exoskeleton may be beneficial to gait rehabilitation with chronic stroke or TBI rehabilitees. The rehabilitees were satisfied with the exoskeleton as a rehabilitation device.
According to the Mayo Clinic, a traumatic brain injury (TBI) “results from a violent blow or jolt to the head or body”. A TBI can also be caused by “an object that goes through brain tissue, such as a bullet or shattered piece of skull. Brain injuries may be caused by falls, vehicle-related collisions, violence, sports injuries, explosive blasts, penetrating wounds, or combat injuries. The degree of damage to the brain may depend on several factors, including the nature of the injury and the force of impact. A TBI can be classified as mild, moderate, or severe. A mild TBI may affect a person’s brain cells temporarily, while more serious TBIs may result in bruising, torn tissues, and other physical damage to the brain. They may result in long-term complications or death.
The physical and psychological effects of a TBI are wide-ranging. While some signs or symptoms may appear immediately after the event, others may appear days or even weeks later. The signs and symptoms of a mild TBI (also known as a concussion) may include headaches, nausea, blurred vision, sensitivity to light or sound, loss of consciousness or a state of being dazed or disoriented, mood swings, depression and anxiety, and sleep issues. The signs and symptoms of moderate to severe TBIs may include those of a mild TBI and may include coma and other disorders of consciousness, convulsions or seizures, clear fluids draining from the nose or ears, slurred speech, agitation, headaches, sensory problems, and other similar symptoms. Infants and young children with an TBI may not be able to communicate their symptoms. Caregivers of children with a TBI may observe a change in eating or nursing habits, unusual irritability, seizures, persistent crying, or a change in sleep habits, among other symptoms.
Research and Resources
Currently, NIDILRR funds over 30 projects whose research and development activities are geared toward improving various aspects of the lives of people with TBI, including interventions, employment, community participation, health, and function. These projects include the TBI Model Systems and the Model System Knowledge Translation Center (MSKTC), which houses evidence-based resources in English and Spanish for consumers with TBI, their families, and service providers.
The Centers for Disease Control and Prevention (CDC) provides information about TBI, including data and statistics, healthcare provider resources, publications, publications and reports, and more. The CDC also provides the CDC Heads Up initiative, which provides information for parents, coaches, school professionals, and healthcare providers on topics TBI and concussion prevention in sports and other TBI risks in children and adolescents.
Interested in research on TBI? NARIC’s information specialists searched REHABDATA and found over 1100 articles related to TBI research from the NIDILRR community and beyond. NARIC’s Research In Focus series discusses the latest results from NIDILRR-funded studies on TBI and disability-related topics presented in an easy to read format.
If you would like to learn more about TBI or would like TBI-related resources, please contact NARIC’s information specialists.
Please Note: See your doctor immediately if you or your child receive a blow to the head or body that concerns you or causes behavioral changes. Seek emergency medical care if there are any signs or symptoms of a TBI after a recent blow or other injury to the head. Although the terms mild, moderate, and severe are used to describe the effect of the injury, a mild TBI is still a serious injury that requires immediate attention and an accurate diagnosis.
[ARTICLE] Proposing Music-based Interventions for the Treatment of Traumatic Brain Injury Symptoms: Current Evidence and Future Directions
Regardless of the classification of initial injury severity, traumatic brain injury (TBI) can result in debilitating neurologic and psychiatric symptoms that may last months to years.1 These post-TBI symptoms can vary widely from patient to patient, but core symptoms involve depressed mood and cognitive impairment.1 The underlying pathophysiology of persistent cognitive dysfunction following TBI has yet to be fully understood, but disruptions in large scale neural networks, particularly those governing resting state functional connectivity (e.g., default mode network) and cognitive control (e.g., salience network), are strongly implicated across TBI severities.2 Furthermore, the presence of post-traumatic depression may have bi-directional interactions on prolonging the overall recovery process.3 Given the deficits in multiple domains of functioning following TBI, novel rehabilitation approaches that can target multiple symptoms simultaneously are needed for this complex neuropsychiatric patient population.
Music-based interventions (MBIs) are emerging as a new potential treatment strategy for neurologic4 and psychiatric5 patient populations, as they are safe, economic, and can be creatively tailored to meet specific functional goals. MBIs are typically selected and delivered by a credentialed music therapist based on empirically supported models and can involve active (improvisation, singing, clapping, or dancing) and/or receptive (purposeful music listening to identify emotional content emerging from music) techniques.4,5 Mechanistically, MBIs appear to engage both cortical and subcortical areas governing attention, working memory, planning, and flexibility and can modulate these areas over time.4
MBIs for TBI
A systematic review and meta-analysis published in 2020 by Mishra et al.6 identified 6 studies of patients with moderate–severe TBI that compared the effect of MBIs for rehabilitation to controls. Five studies were of low quality and 1 study was very low quality. Outcomes were focused on recovery of motor symptoms and on cognitive functioning. Three studies reported significant improvements in gait velocity and stride length with small overall effect. Mixed results were reported for cognitive outcomes with no significant improvement in memory (one study reporting overall worsening of memory), and 3 studies reporting improvement in executive functioning with small overall effect. Finally, only 2 of the included studies evaluated changes in depressed mood following MBIs, and although both reported statistically significant improvements, the heterogeneity of outcome measures used between these studies limits any generalizability. Overall, this meta-analysis was limited by the low number of studies, low study quality, small sample sizes (n < 30) within included studies, heterogeneity in outcome measures used, and lack of follow-up data.6
A recent crossover randomized control trial not included in the above systematic review found significant improvements in general executive functioning and set shifting skills in moderate-severe TBI (n = 39) following 3 months of MBIs.7 Each session occurred twice weekly and included three 20-minute modules involving rhythmic training (playing sequences of rhythms on a drum), structured cognitive-motor training (playing musical exercises on drum set with different movement in composition elements while accompanied by the MT on piano), and assisted music playing (learning to play participants’ favorite songs on piano). The executive function improvements were maintained at 6-month follow up, and the investigators found significant increases in grey matter volume in the right inferior frontal gyrus, which correlated with improvements in set shifting.7 This evidence further supports that MBIs can influence cognitive outcomes following TBI and that this could be due to engagement of corresponding neural networks.
Although injury severity was not reported in the following study, Gardiner and Horwitz8 reported significant improvements in planning (as measured by a series of mazes from the Weschler Intelligence Scale-III), and mental flexibility (Trail making test-B) in 22 veterans with TBI after employing specific MBI protocols targeting attention, executive function, and memory. Notably, the conclusions of these findings are limited by the open-label pretest–posttest design with no randomization or control/comparator group.
Only one study was found that evaluated the effects of MBIs on mild TBI. Vik et al.9 evaluated the effects of biweekly 30-minute piano instruction for patients (n = 7) following mTBI compared with 2 healthy control groups (musicians, n = 11, and non-musicians, n = 12). Piano exercises gradually progressed in difficulty, and patients were additionally required to practice at home for 15 minutes per day. All 7 mTBI patients had received traditional cognitive rehabilitation during their hospital stay without improvement and were all on leave from work, despite being on average 2 years post injury. Patients with mTBI not only experienced significant improvements in California Verbal Learning Test performance, but 6 of the 7 patients returned to work in their full pre-morbid capacity. Furthermore, these clinical changes were coupled with increased connectivity between right middle prefrontal cortex, right anterior insular cortex, left rostral anterior cingulate cortex, and the right supplementary motor cortex,9 which are important nodes in the salience and frontal-executive neural networks.2
Conclusions and Future Directions
Cognitive impairment and depression in TBI are commonly reported symptoms and there are limited interventions available to effectively manage them.1,3 MBIs are emerging as a novel multimodal therapeutic strategy with the potential to target several symptom domains simultaneously.4 There is promising evidence to suggest that MBIs may have potential in rehabilitating cognitive impairments across various levels of TBI severity with most evidence for moderate–severe TBI.6,7 However, conclusions on efficacy are limited at this time given the lack of randomized trials for each level of injury severity (e.g., only 1 study for mild TBI9) small sample sizes, lack of active control groups, and overall poor study quality. It is possible that MBIs exert their effects by engaging dysfunctional neural networks implicated in TBI, but at this time, only 2 studies have investigated this relationship with fMRI; one for mild TBI9 and one for moderate–severe.7
With regards to post-TBI depression, only 2 studies included in the meta-analysis for moderate–severe TBI included mood outcomes, but they both reported statistically significant improvements.6 MBIs have been shown to have a large effect with moderate quality evidence for depression (not specific to TBI) according to a recent Cochrane review.5 Since depression is recognized as a common symptom across TBI severity that impacts functional outcomes,1,3 it is critical that future studies of MBIs for TBI include pre–post measures of validated depression scales.
Overall, further studies are needed to determine if MBIs can demonstrate efficacy with randomized controlled trial designs and to further understand underlying neurobiological mechanisms of this therapy with use of pre/post neurophysiological measures. Preferably, future studies will employ traditional cognitive rehabilitation strategies as a comparator group, as the above studies only compared MBIs to standard care or waitlist, as well as longer follow-up periods and evaluation of transfer to real-world functioning. Given that TBI-related cognitive impairment has limited treatment options and MBIs have no major risk of harm, we would recommend that integrated inpatient and outpatient treatment programs for moderate-severe TBI consider incorporating MBIs into their clinical management plans. The relative lack of available evidence of MBIs for mild TBI limits the generalizability of recommendations at this time, although, given the safety profile and similar limited treatment options, MBIs could be offered where resources are available. Ideally, delivery of MBIs would be carried out by a trained music therapist in collaboration with either an occupational or physical therapist following a validated protocol.8,9,7 There is potential to deliver MBIs by a credentialed music therapist virtually as well. However, many communities may not have access to therapists of specialized resources, and modified protocols could be developed that are self-directed (e.g., learning an instrument via internet or phone-based applications, memorizing lyrics and singing along to favourite songs, or tapping along to the beat while listening to their favourite pieces of music, for at least 15 minutes daily), although collaboration among local university-based music therapy departments (if applicable) would be recommended. Additional resources and information on university-based music therapy programs and credentialed therapists can be found at https://www.musictherapy.ca/ or www.nmtacademy.co
[Abstract] Neuroprotective Properties of Vitamin C: A Scoping Review of Pre-Clinical and Clinical Studies
There is a need for novel neuroprotective therapies. We aimed to review the evidence for exogenous vitamin C as a neuroprotective agent. MEDLINE, Embase, and Cochrane library databases were searched from inception to May 2020. Pre-clinical and clinical reports evaluating vitamin C for acute neurological injury were included. Twenty-two pre-clinical and 11 clinical studies were eligible for inclusion. Pre-clinical studies included models of traumatic and hypoxic brain injury, subarachnoid and intracerebral hemorrhage, and ischemic stroke. The median [IQR] maximum daily dose of vitamin C in animal studies was 120 [50–500] mg/kg. Twenty-one animal studies reported improvements in biomarkers, functional outcome, or both. Clinical studies included single reports in neonatal hypoxic encephalopathy, traumatic brain injury, and subarachnoid hemorrhage and eight studies in ischemic stroke. The median maximum daily dose of vitamin C was 750 [500–1000] mg, or ∼10 mg/kg for an average-size adult male. Apart from one case series of intracisternal vitamin C administration in subarachnoid hemorrhage, clinical studies reported no patient-centered benefit. Although pre-clinical trials suggest that exogenous vitamin C improves biomarkers of neuroprotection, functional outcome, and mortality, these results have not translated to humans. However, clinical trials used approximately one tenth of the vitamin C dose of animal studies.
Rhythmic auditory stimulation (RAS) has been well researched with stroke survivors and individuals who have Parkinson’s disease, but little research exists on RAS with people who have experienced traumatic brain injury (TBI). This pilot study aimed to (1) assess the feasibility of the study design and (2) explore potential benefits. This single-arm clinical trial included 10 participants who had a 2-week control period between baseline and pretreatment. Participants had RAS daily for a 2-week treatment period and immediately completed post-treatment assessments. Participants then had a 1-week control period and completed follow-up assessment. The starting cadence was evaluated each day of the intervention period due to the variation in daily functioning in this population. All 10 participants were 1-20 years post-TBI with notable deviations in spatial-temporal aspects of gait including decreased velocity, step symmetry, and cadence. All participants had a high risk of falling as defined by achieving less than 22 on the Functional Gait Assessment (FGA). The outcome measures included the 10-m walk test, spatial and temporal gait parameters, FGA, and Physical Activity Enjoyment Scale. There were no adverse events during the study and gait parameters improved. After the intervention, half of the participants achieved a score of more than 22 on the FGA, indicating that they were no longer at high risk of experiencing falls.
[ARTICLE] Resting-State Network Plasticity Induced by Music Therapy after Traumatic Brain Injury – Full Text
Traumatic brain injury (TBI) is characterized by a complex pattern of abnormalities in resting-state functional connectivity (rsFC) and network dysfunction, which can potentially be ameliorated by rehabilitation. In our previous randomized controlled trial, we found that a 3-month neurological music therapy intervention enhanced executive function (EF) and increased grey matter volume in the right inferior frontal gyrus (IFG) in patients with moderate-to-severe TBI (). Extending this study, we performed longitudinal rsFC analyses of resting-state fMRI data using a ROI-to-ROI approach assessing within-network and between-network rsFC in the frontoparietal (FPN), dorsal attention (DAN), default mode (DMN), and salience (SAL) networks, which all have been associated with cognitive impairment after TBI. We also performed a seed-based connectivity analysis between the right IFG and whole-brain rsFC. The results showed that neurological music therapy increased the coupling between the FPN and DAN as well as between these networks and primary sensory networks. By contrast, the DMN was less connected with sensory networks after the intervention. Similarly, there was a shift towards a less connected state within the FPN and SAL networks, which are typically hyperconnected following TBI. Improvements in EF were correlated with rsFC within the FPN and between the DMN and sensorimotor networks. Finally, in the seed-based connectivity analysis, the right IFG showed increased rsFC with the right inferior parietal and left frontoparietal (Rolandic operculum) regions. Together, these results indicate that the rehabilitative effects of neurological music therapy after TBI are underpinned by a pattern of within- and between-network connectivity changes in cognitive networks as well as increased connectivity between frontal and parietal regions associated with music processing.
Each year, there are over 50 million cases of traumatic brain injury (TBI), and it has been estimated that approximately half of the world’s population will sustain at least minor TBIs during their lifetime . The consequences of TBI can be fatal; it is the leading cause of mortality in young adults and a major cause of death and disability across all ages worldwide. Depending on the injury mechanism, TBI can cause different pathophysiological changes in the brain such as diffuse axonal injury (DAI), bleeding, and contusions. Due to TBI’s widespread effects that are dominant in the white matter tracts, it can be viewed foremost as a disorder of large-scale intrinsic connectivity networks . DAI has also been shown to correlate with persistent cognitive impairments after TBI . Despite the broad variety of symptoms that can follow after TBI, the most prominent cognitive impairments affect attention, memory, and executive function (EF) [1, 3–6]. These high-level cognitive functions require the integration of information across spatially distinct brain regions, which make them particularly vulnerable to connectivity problems. In fact, deficits in EF are deemed to be the core symptoms of TBI [7, 8], particularly in moderate-to-severe cases that are at focus here. Although there is no consensus on the exact definition of EF, it is thought to encompass several cognitive processes including the core set of shifting, inhibition, and updating . Given the heterogeneous and complex nature of TBI and the major burden imposed upon individuals and society, there is an urgent need to develop novel and motivating rehabilitation strategies that target multiple deficits simultaneously, yet with a primary focus on EF.
Music is a very promising tool in TBI rehabilitation, because both music listening and participating in musical activities evoke widespread brain activation . Musical creativity has recently been linked to the functioning of various resting-state networks including the default mode, executive, salience, limbic, and motor-planning networks . It has also been shown that musical training enhances EF in healthy subjects and increases the engagement of the cognitive control network, which shares most of its nodes with the frontoparietal network [12–20]. Crucially, music has been shown to be an effective tool in enhancing cognitive and emotional recovery in neurological patients [21–24]. Since brain injury patients are usually able to enjoy and participate in musical activities , neurological music therapy can potentially contribute to restore the EF deficits observed in TBI patients . Until recently, this question had been addressed by only three studies exploring the cognitive effects of music-based interventions after TBI [27–29]. Evidence from these studies indicated that music-based rehabilitation can indeed lead to cognitive recovery after brain injury, especially in the domain of mental flexibility, as well as activity and connectivity changes involving the orbitofrontal cortex, whose damage after TBI is associated with behavioral impairment . However, these studies presented important limitations with regard to the sample size, lack of a proper randomized controlled design including a patient control group, and inclusion of patients with brain injury not caused by trauma.
We have conducted the first-ever randomized controlled trial (RCT) of neurological music therapy in a cohort of 40 moderate-to-severe TBI patients, where different domains of EF, attention, and memory were systematically analyzed. We used a single-blind cross-over design with 3 timepoints (baseline/3 months/6 months) for neuropsychological assessment and s/fMRI acquisition. The neurological music therapy consisted of 20 individual therapy sessions held by a trained music therapist over a 3-month period (see Materials and Methods for more details) and was targeted primarily to the rehabilitation of EF, attention, and working memory. In a previous publication, we reported that the music-based intervention induced cognitive improvement in general EF performance as well as in set-shifting .
In addition to demonstrating this improvement in neuropsychological performance, in , we conducted a voxel-based morphometry (VBM) analysis to investigate the volumetric changes induced by the music therapy. This analysis was motivated by a previous work showing that environmental enrichment, such as that provided by musical activities, can increase the cognitive reserve and promote adaptive structural neuroplasticity changes [32–34], including stroke patients . Our VBM results indicated that TBI patients showed an increase in grey matter volume (GMV) in different brain regions involved in music processing and cognitive function after the intervention. A therapy-induced increase in GMV was seen especially in the right inferior frontal gyrus and was correlated with enhanced set shifting ability.
Resting-state functional connectivity (rsFC) is characterized by task-free spontaneous fluctuations in brain activity that occur synchronously across spatially distant regions . These fluctuations can be measured with the blood-oxygen-level-dependent response at low frequencies (usually under 0.15 Hz) and are spatially organized in resting-state networks (RSNs)  that mirror activity evoked during cognitive tasks [37, 38]. Examining rsFC after TBI is an active area of investigation motivated by the fact that DAI, a common pathology reported in all severities of TBI [39, 40], damages axonal wiring that partly underlies functional connectivity across RSNs . The loss of integration of information in large-scale brain networks, which ultimately impairs high-level cognitive function, makes the study of rsFC after brain injury especially relevant [36, 41–43].
rsFC studies of TBI patients have revealed both increases and decreases in network connectivity, including the default mode (DMN) and salience (SAL) networks as well as multiple sensory and cognitive networks across the spectrum of injury severity [44–49]. For example, decreased rsFC has been observed within five network pairs (DMN-basal ganglia, attention-sensorimotor, frontal-DMN, attention-frontal, and sensorimotor-sensorimotor; ) and within the motor-striatal network, in contrast to increased connectivity within the right frontoparietal network (FPN) . In several cases, these abnormalities correlated with postconcussive symptoms [44, 48] and cognitive impairment .
Despite the complex abnormalities of interactions within and between RSNs following TBI, it is possible to identify some distinctive patterns. Within networks, reduced rsFC within the nodes of the DMN predicts attentional impairment . Such association could be driven in turn by damage to the cingulum bundle connecting the nodes of the DMN. The temporal coordination between networks, which is important for efficient high-level cognitive function, has also shown consistent abnormalities after TBI. According to an influential model of cognitive control , the switching from automatic to controlled behavior is mediated by the interaction between the SAL and DMN networks, including deactivation of the DMN to attend unexpected external events. Indeed, TBI patients exhibit a failure to appropriately deactivate the DMN, which is associated with impaired response inhibition to a stop signal .
The paradoxical yet well-documented finding that functional connectivity may increase secondary to TBI [44–46, 52–56] has given rise to the “hyperconnectivity” hypothesis to explain the evolution of brain network reorganization after neurological disruption . In this context, hyperconnectivity is defined as enhanced functional connectivity in the number or strength of connections. It is thought to affect preferentially RSNs with high-degree nodes, also known as network hubs, such as the frontoparietal (FPN), DMN, and SAL networks. Although this hyperconnected state may be adaptive in the short term in order to reestablish network communication through network hubs, Hillary and Grafman  have argued that it may have negative consequences due to the chronic enhancement of brain resource utilization and increased metabolic stress. In support of this view, abnormal functional connectivity has been associated with increased self-reported fatigue, which is a highly common and debilitating symptom after TBI . Over a longer period of time, this hyperconnectivity may even lead to late pathological complications including Alzheimer’s disease [59, 60], where amyloid beta deposition has been linked to the neurodegeneration of posterior DMN hubs with high metabolic rate [61–63].
In the present study, we extend our previous findings by analyzing rsFC from a subset of moderate-to-severe TBI patients (see Materials and Methods for more details) in this music therapy RCT . We used a seed-to-target approach to analyze the reconfiguration of RSNs induced by the neurological music therapy, selecting seeds from the nodes of four key networks: the DMN, SAL, FPN, and dorsal attention (DAN) networks. The current work is grounded in two main hypotheses: (1) the music-based intervention leads to enhanced coordination activity between attention and executive function (DAN, FPN) supporting networks and sensory networks that are engaged during the music therapy; and (2) the music-based intervention elicits reduced connectivity of nodes within the SAL, DMN, and FPN networks. In addition, we examined the relationship between the changes in rsFC within and between networks and the therapy-induced improvement in EF shown previously with neuropsychological testing . We anticipated that the FPN would be less connected in TBI patients with better EF performance, as the hyperconnectivity hypothesis predicts. Lastly, in a similar vein to the approach adopted by Han et al. , we conducted an exploratory seed-to-voxel analysis to elucidate the link between whole-brain rsFC and GMV enhancements induced by the neurological music therapy.[…]
INTRODUCTION: Comorbidities in persons with traumatic brain injury (TBI) may negatively impact injury recovery course and result in long-term disability. Despite the high prevalence of several categories of comorbidities in TBI, little is known about their association with patients’ functional outcomes. We aimed to systematically review the current evidence to identify comorbidities that affect functional outcomes in adults with TBI.
EVIDENCE ACQUISITION: A systematic search of Medline, Cochrane Central Register of Controlled Trials, Embase, and PsycINFO was conducted from 1997 to 2020 for prospective and retrospective longitudinal studies published in English. Three researchers independently screened and assessed articles for fulfillment of the inclusion criteria. Quality assessment followed the Quality in Prognosis Studies tool and the Scottish Intercollegiate Guidelines Network methodology recommendations.
EVIDENCE SYNTHESIS: Twenty-two studies of moderate quality discussed effects of comorbidities on functional outcomes of patients with TBI. Cognitive and physical functioning were negatively affected by comorbidities, although the strength of association, even within the same categories of comorbidity and functional outcome, differed from study to study. Severity of TBI, sex/gender, and age were important factors in the relationship. Due to methodological heterogeneity between studies, meta-analyses were not performed.
CONCLUSIONS: Emerging evidence highlights the adverse effect of comorbidities on functional outcome in patients with TBI, so clinical attention to this topic is timely. Future research on the topic should emphasize time of comorbidity onset in relation to the TBI event, to support prevention, treatment, and rehabilitation. PROSPERO registration (CRD 42017070033).
Diffusion tractography magnetic resonance imaging (MRI) can infer changes in network connectivity in patients with traumatic brain injury (TBI), but the pathological substrates of disconnected tracts have not been well defined because of a lack of high-resolution imaging with histopathological validation. We developed an ex vivo MRI protocol to analyze tract terminations at 750-μm isotropic resolution, followed by histopathological evaluation of white matter pathology, and applied these methods to a 60-year-old man who died 26 days after TBI. Analysis of 74 cerebral hemispheric white matter regions revealed a heterogeneous distribution of tract disruptions. Associated histopathology identified variable white matter injury with patchy deposition of amyloid precursor protein (APP), loss of neurofilament-positive axonal processes, myelin dissolution, astrogliosis, microgliosis, and perivascular hemosiderin-laden macrophages. Multiple linear regression revealed that tract disruption strongly correlated with the density of APP-positive axonal swellings and neurofilament loss. Ex vivo diffusion MRI can detect tract disruptions in the human brain that reflect axonal injury.
Although the vast majority of people recover after a concussion (guess what? a concussion IS a brain injury)…….how quickly they improve, rehabilitate, and return to their daily activities depends on many factors. These factors include how severe their concussion was, their age, how healthy they were before the concussion, how they take care of themselves after the injury, and the resources provided to them regarding their aftercare/recovery process (this means being provided with proper directions, follow up, and educational information by good providers who know what they are doing).
Okay, we say “good providers”. I do want to say that brain science is changing and evolving on a daily basis. It may not be possible for your provider to know all the latest and greatest developments regarding brain injury recovery, so don’t be too hard on them. It is also difficult for the rehabilitation team of providers to know exactly how long a recovery will take, especially at the beginning. This is why it is called “practicing medicine” – not everything is certain or known. The more you know, the more you realize that once you’ve seen one brain injury you’ve seen one brain injury. This means that all brain injuries, and healing abilities from those brain injuries are different (even if they share similar symptomology). A “good provider” would be someone who advocates for their patient, or defers their patient to a provider with specialized training, or who acts as an active listener and guide through the recovery process (even if that means being willing to learn about new scientific breakthroughs and keeping up on their skills, and knowledge base around what they are treating you for). Is that clear as mud? LOL
Do not compare your concussion (brain injury) symptoms and recovery to that of someone else or even to any previous concussions you may have sustained. Each persons injury is different, and the symptoms of each brain injury(even when happening to the same person) may be different and require a different rehabilitation time as well.
It has been established time and time again that recovery is usually fastest in the early weeks and months after brain injury. In the first few weeks after a brain injury, swelling, bleeding or changes in brain chemistry and physiological aspects of the brain are often affected, and affect the function of healthy brain tissue. The fastest improvement usually happens in about the first six months after injury. During this time, the injured person will likely show a vast array of improvement and may even seem steadily be getting better. The person continues to improve between six months and two years after injury, but this varies greatly for different people and may not happen as fast as the first six months. It is important to note though that while improvements slow down substantially after two years….additional healing and progress may still occur many years after injury. Also the opposite is true as well. A person who appears to be recovered or rehabilitated may not experience affects or manifestation of their injury until years later.
There are some poignant things to keep in mind regarding recovery from a brain injury.
- If you suffered from anxiety or depression before your head injury, it may make it harder to adjust to the symptoms of a concussion (brain injury)
- If you already had a medical condition at the time of your concussion (such as chronic headaches or chronic pain), it may take longer for you to recover
- Receiving another concussion before the brain has healed can result in brain swelling, exacerbated symptoms, permanent brain damage, coma, or death – especially in our youth. You should therefore avoid activities that could cause you to jolt, bump, hurt, or cause a blow to be made to your head.
- If you are a woman (female) it may take you longer to recover and you may have more severe symptoms that your male counterparts.
- Numerous Concussions (brain injuries) over time may cause you to have ongoing serious long-term problems, including chronic memory challenges, difficulty with concentration, persistent headaches, and occasionally, diminished fine motor/physical skills (such as keeping the ability to stay balanced or walk in a straight line).
After reading all this, the question presents itself as,
“Great! Then what things CAN I do to improve my rehabilitation process?”
After all, that’s why you are here to see what that burning question will reveal, right?!?!
- 1. Vision Testing –
- I don’t mean like your typical eye doctor or optometrist/ophthalmologist that you would see to get your vision tested for glasses. or your glasses prescription adjusted. They don’t have the specialized training for the help you may need. I am talking about seeing a Neuro-Ophthalmologist/Optometrist (yes there is a difference). A Neuro Optometrist is trained to diagnose and treat neurological conditions that negatively impact the visual system. A Neuro-Ophthalmologist is a medical doctor that specializes in the diagnosis and treatment/rehabilitation of neurological conditions adversely affecting the visual system and specializes in neurology AND ophthalmology.
- They specialize in visual problems that relate to the nervous system (brain injury, stroke, Parkinson’s disease, multiple sclerosis, and diabetic neuropathy). They help patients rehabilitate their vision with specific visual exercises/eye-training exercises that rewire the brain (neuroplasticity). These exercises can be done in the office during a scheduled appointment or at home with the aim being to reduce symptoms and promote visual recovery. These exercises are designed to improve balance, gait, visual information processing, cognitive skills, visual memory, motor skills, double vision, tracking/scanning problems, inability to focus, loss of central vison, strabismus (eye turning), convergence insufficiency, visual field loss, issues with depth perception, etc.
- They may also, for some patients, prescribe specific optical lenses called prisms (prism glasses)
- The treatment from this may last weeks, months, and for some patients – years.
- See additional information about VISION THERAPY.
- 2. Auditory Testing (hearing tests) –
- Hearing issues are often overlooked in polytrauma patients because of other visible life threatening injuries that often take medical precedence/priority. However, hearing loss may mask or confuse getting a correct diagnosis for other injuries. Some patients have been diagnosed as being unresponsive or uncooperative when it was their hearing that was affected. Issues with the ear can result in problems related to balance, hearing loss, dizziness, vertigo ( the most common vertigo being benign paroxysmal positional vertigo), tinnitus (ringing in the ear), chronic nausea, and headaches. While some of these changes are reversible, others are not. This is the importance of getting auditory testing completed as soon as possible after a head injury.
- Dizziness is believed to occur in 40-60% of people with traumatic brain injuries. The ear is also the organ that is the most susceptible to blast exposures. The extent of ear damage from a blast depends on a multitude of factors (size of blast, environment, distance from blast, orientation of ear canal to the blast, open or closed area during blast). The most common injury from a blast is a ruptured eardrum (tympanic membrane). There are also cases of traumatically induced Meniere’s Disease.
- Hearing loss as a result of brain injury causes damage to the inner ear or because there is damage to the brain that produces sound. Auditory problems could be mistake for signs of cognitive deficits attributed directly to a brain injury. Hearing loss also exacerbate the social, emotional, and cognitive affects of the brain injury. It is possible to have cognitive affects related to brain injury AND loss of hearing at the same time.
- Auditory symptoms may include difficulty understanding speech, especially when there is background noise; difficulty locating sounds (knowing where the sounds are coming from); hyperacusis (extreme sensitivity to sounds); tinnitus (ringing in the ears with no external source of the sound); conductive or sensorineural hearing loss ( damage either to the tiny hair cells in your inner ear – known as stereocilia, or to the nerve pathways that lead from your inner ear to the brain); distorted hearing, etc.
- 3. Speech Therapy –
- Brain injuries can cause speech, language, thinking, and swallowing problems. Speech therapists treat all these conditions
- Types of issues treated are dysarthria (when the muscles you use for speech are weak or you have difficulty controlling them causing slurred or slowed speech that can be difficult to understand), aphasia (impairment of language, affecting the production or comprehension of speech and the ability to read or write), improving cognitive communication skills, and improving memory
- Goals in treatment by a Speech Language Pathologist (SLP)/speech therapist is to help the person speak more clearly; express thoughts more effectively; improve problem-solving, planning, and organization skills; improve speech to make it clearer; reading comprehension skills; improvement of memory using various tools (calendars, notebooks, to-do lists, post-it notes, planner, white boards, etc); learn ways to swallow safely; work on social skills through reading and social cues, etc.
- 4. SPECT CT –
- CT and MRI scans provide detailed information on the anatomical structure of the brain. Brain SPECT imaging reveals the function of the brain by measuring blood flow.
- Functional brain imaging is not considered a stand-alone diagnostic tool. While there are varying levels of acceptance among the neurological and psychiatric conditions, the science and technology have been research for decades and there are hundreds of published research studies utilizing SPECT for the evaluation of the various conditions.
- See our article – SPECT CT
- 5. Rest –
- Rest and proper sleep is very important after a concussion because it helps the brain to heal. Ignoring their symptoms and trying to “tough it out” often makes symptoms worse. Physical and cognitive rest is often recommended, however this varies greatly depending on the health of the brain prior to the injury, as well as the force sustained.
- These activities, patients are advised by healthcare providers to rest from after a brain injury include: reading, using a computer, watching television, playing video games, or working on school assignments. For many people, physical and mental rest until symptoms subside is the only treatment needed for a concussion or other head injury.
- During the first 24 hours, the brain needs as much rest as possible, including minimizing mental, and physical stimulation.
- After 24 hours, if the injured is symptom-free, the injured person may begin the “relative rest” progressive protocol. Relative rest refers to avoiding any mental or physical activity that provokes the concussion-related symptom (for example if they participate in a physical activity and it increases symptoms, then stop that particular activity)
- Each day a person can add more mental and physical exertion, as long as their activities don’t provoke any concussion symptoms. It is advised to avoid any strenuous exercise for a week or so. If you want to keep exercising, try to keep it light. If you’re a runner, for example, try walking. It’s also best to avoid any heavy lifting for a week. Moderate activity over the long term helps reduce effects of depression, feelings of isolation,
- Regardless of the severity of your concussion (brain injury), you should be symptom-free before returning to normal activity, and your condition should be carefully monitored by your doctors.
“NEVER GIVE UP ON A HEAD INJURED PATIENT. – Recovery Occurs for the rest of a person’s life. Give people the type of treatment that they deserve. ~David Hovda, PhD“