[ARTICLE] Resting-State Network Plasticity Induced by Music Therapy after Traumatic Brain Injury – Full Text

Abstract

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.

1. Introduction

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 [1]. 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 [2]. DAI has also been shown to correlate with persistent cognitive impairments after TBI [3]. 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 [9]. 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 [10]. 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 [11]. 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 [25], neurological music therapy can potentially contribute to restore the EF deficits observed in TBI patients [26]. 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 [30]. 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 [31].

In addition to demonstrating this improvement in neuropsychological performance, in [31], 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 [22]. 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 [35]. 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) [36] 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 [3]. 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; [49]) and within the motor-striatal network, in contrast to increased connectivity within the right frontoparietal network (FPN) [47]. In several cases, these abnormalities correlated with postconcussive symptoms [44, 48] and cognitive impairment [50].

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 [41]. 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 [51], 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 [41].

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 [57]. 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 [57] 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 [58]. 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 [31]. 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 [31]. 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. [64], 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.[…]

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[Abstract] Comorbidity in traumatic brain injury and functional outcomes: a systematic review

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).

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[Abstract] Tractography-Pathology Correlations in Traumatic Brain Injury: A TRACK-TBI Study

Abstract

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.

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[BLOG POST] 5 Important Brain Injury Recovery Steps – HOPE TBI

February 12, 2021 HOPE TBI

Brain Injury Recovery Steps

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?!?!

Neuro Optometry

• 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.

Auditory Testing

• 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“

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[Abstract] Moderate Intensity Treadmill Exercise Increases Survival of Newborn Hippocampal Neurons and Improves Neurobehavioral Outcomes after Traumatic Brain Injury

Abstract

Physician-prescribed rest after traumatic brain injury (TBI) is both commonplace and an increasingly scrutinized approach to TBI treatment. Although this practice remains a standard of patient care for TBI, research of patient outcomes reveals little to no benefit of prescribed rest after TBI, and in some cases prolonged rest has been shown to interfere with patient well-being. In direct contrast to the clinical advice regarding physical activity after TBI, animal models of brain injury consistently indicate that exercise is neuroprotective and promotes recovery. Here, we assessed the effect of low and moderate intensity treadmill exercise on functional outcome and hippocampal neural proliferation after brain injury. Using the controlled cortical impact (CCI) mouse model of TBI, we show that 10 days of moderate intensity treadmill exercise initiated after CCI reduces anxiety-like behavior, improves hippocampus-dependent spatial memory, and promotes hippocampal proliferation and newborn neuronal survival. Pathophysiological measures including lesion volume and axon degeneration were not altered by exercise. Taken together, these data reveal that carefully titrated physical activity may be a safe and effective approach to promoting recovery after brain injury.

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[WEB PAGE] Getting REAL About Functional Therapy

By Tracie Hunnicutt, MS, CCC-SLP; Julie Clement, OTR; and Susan Adix, PT

Patients enter inpatient rehabilitation facilities for countless reasons, but always share a common goal—independence. Each patient may define independence differently, but the ultimate goal for all is to recover function in the skill sets that allow them to return to their chosen activities at home or in the community. The foundation for successful recovery of function is task specificity. Research has shown that physical rehabilitative therapy focused on task-specific training produces more meaningful functional improvements than therapy based on high-intensity repetitive exercise alone.¹ This is true regardless of age or diagnosis, and is particularly relevant for patients who are recovering from a neurologic event. When the neurophysiologic goal is to impact plasticity, it is critical that the activities chosen for therapy are the very same activities that patients will be returning to at home or in the community. Task-specific practice results in greater cortical representation and reorganization in recovering neuro patients.¹ In patient populations other than neuro, task specificity may not be necessary to impact plasticity, but can and will incrementally improve both patient performance and confidence.

Functional therapy begins with a skilled therapist invested in developing an individualized care plan suited to the patient’s needs and interests. The joint nature of the care plan should start during a thorough patient history, where both skill and intuition are necessary to identify what is important to the patient, and what therapy tasks can most closely resemble the patient’s desired activities. Physical therapists, occupational therapists, and speech language pathologists all spend a large portion of their work day adjusting tasks or manipulating the surrounding environment to simulate a patient’s home and community activities. This can present a challenge during the inpatient portion of a patient’s recovery in both acute care and inpatient rehabilitation settings, which are hospital-based and designed with patient safety and ease of function as priorities. The contrast between what the environment demands from a patient in a hospital versus the demands of home and community is vast, and can be a surprise and a risk to patients who are not prepared.

From this clinical need arose a new treatment tool—Realistic Environment Applied Learning, or REAL Therapy. REAL Therapy is a community simulation environment with ready-made functional therapy tasks available to patients and clinicians from the moment they enter the room. Because the environment is task-specific, and does not require modification by the therapist, the entire time spent in therapy can address the physical and cognitive demands of real-life activities performed by the patient. REAL Therapy is comprised of various modules that each have a unique clinical focus. Modules were designed to address some of the most common community-based locations patients visit upon discharge. Available modules include a grocery store, restaurant, deli, laundromat, and a car transfer/gas station area.

The grocery shopping module helps patients use their OT skills when grasping various-sized items, and PT skills when navigating the aisle and reaching for the products at multiple levels. Items are weighted to actual scale to closely simulate the experience of being in a real store.

Grocery Store

The grocery store module is the most versatile and commonly used area of REAL Therapy. Opportunities for functional therapy tasks abound, and physical therapists, occupational therapists, and speech pathologists alike utilize this module daily because of the variety of tasks that can be performed. The grocery store includes standard grocery shelving with a height of 72 inches, stocked with realistically weighted items. There is an area with fruit and vegetables that must be hand selected and weighed, as well as a bakery. A freezer with cold storage contains commonly refrigerated items. There are shopping carts and baskets, a working checkout counter, a register, and an ATM.

Some of the common physical tasks include dynamic balance activities such as pushing a shopping cart, carrying a shopping basket, reaching for objects on high shelves, reaching for objects on low shelves, reaching for objects at the back of shelves, opening the glass door and selecting items from cold storage, picking up heavy or bulky objects, retrieving items from a shopping cart and placing them on the checkout counter, bagging items, and carrying bags out of the store. Some of the common cognitive tasks include creating and executing a shopping list, locating difficult-to-find items, reading labels, calculating totals, money management, operating a credit card machine, staying within a budget, using memory strategies to recall short lists of items, and identifying obstacles and safety hazards.

This module is used frequently because it represents an essential community location that up to 84% of geriatric adults visit regularly.² Community-based locations specific to food and medical care are among the most commonly visited sites for older adults. Therefore, task-specific practice with a skilled therapist is likely to be a precursor for greater success and safety when patients are functioning in these locations post-discharge.

Restaurant

The restaurant is another module with a variety of applications depending on the patient’s individual needs or preferences. There are various settings within the restaurant, each with its own challenges to the patient. There is indoor booth-style seating for one table and outdoor seating/patio furniture for another, complete with a table umbrella.

Physical tasks for this module include getting into and out of a booth with limited space, pulling out chairs to sit down and repositioning closer to the table once seated, raising or lowering the table umbrella, reaching across the table to receive food from a server, and identifying a space to place any necessary assistive devices (ie, walkers, wheelchairs, canes, etc) while at the table. Common cognitive or communication tasks for this module include reading a menu, making menu choices that consider dietary restrictions or special needs, communicating with wait staff, verbalizing an order, participating in conversation and socialization during a meal, estimating a bill, calculating a tip, completing and signing the check, and time management.

With the café module, patients can use speech skills to call out certain items, while using PT skills to navigate the cafeteria line, as well as OT skills to pick up items. Cognitive skills such as math and memory may be practiced by asking patients to select items below a certain dollar amount.

Deli

The deli module includes a glass-faced display case from which patients can view and select their food options. There is a metal tray line in front of the display case followed by a drink and condiment station. This module demands more from the patients from a mobility standpoint, and is less flexible in terms of the ability to modify the physical tasks that can be performed.

Common physical tasks for the deli include standing and reaching into the display case to obtain food, placing items on the tray, pushing the tray down the line as it gains an increasing amount of weight, moving the tray to the drink station, obtaining the desired drink and condiments, carrying the tray, and getting into and out of seating. The deli has an elevated barstool-type seating area, and the restaurant module seating may also be used. Where the deli lacks some flexibility in physical modification of tasks, it is particularly useful in the patient’s ability to problem-solve in a challenging, less forgiving environment.

Cognitively, the patient must determine if he or she has the ability to perform the necessary tasks, or if it would be safer to request help with the physical components of this setting. Elements of the deli environment, such as bilateral upper extremity use to open the case and obtain the food or propelling and carrying the tray, may require the assistance of another person, as they cannot be easily modified. Cognitive tasks in the deli include visual scanning, sequencing food choices (ie, salad, main dish, dessert, drink), making food choices that are compliant with dietary needs, estimating cost, money management, and identification of barriers or safety hazards.

Laundromat

The laundry module can represent a community-based laundromat or a home-based laundry room. This module includes a top-loading washer, a front-loading dryer, an ironing board, and an elevated folding table that also has a place for hanging clothes. Common physical tasks in the laundromat include picking up large piles of both wet and dry clothing, picking up heavy containers of detergent or fabric softener, loading and removing clothing from the washer, bending to load and remove clothing from the dryer, carrying a laundry basket, folding clothes, ironing clothes, and hanging clothes. Common cognitive tasks in this module include sorting and organizing clothing, calculating how much detergent or fabric softener to use, and time management. If this module is being used to simulate an actual laundromat, there is an available change machine to include the money management portion of the activity.

One common goal among HealthSouth Arlington’s patients is the ability to drive or safely get from one place to another. The car transfer simulator is adjustable to the height of the patient’s personal vehicle, and therapists use it to help patients learn how to safely transfer in and out of the vehicle.

Car Transfer / Gas Station

In addition to the grocery store, the car transfer/gas station module is one of the more frequently utilized areas of REAL Therapy. Safe and effective car transfers are often one of the keys to a patient’s continued community involvement, as well as access to necessities and medical care following hospitalization. The inability to perform this task has been linked to decreased quality of life, increased burden of care, and the possibility of institutional living.³ In certain patient populations such as spinal cord injury, correct execution of car transfers is even more critical to prevent pain and injury that could compromise a patient’s overall independence.⁴ The REAL Therapy module features a car transfer simulator. The simulator is the front end of a car, with working doors, handles, locks, seat belts, bench or bucket seats, gas pedal, brake, steering wheel, and a behind-seat wheelchair loading area. The car simulator is height adjustable, so that therapists may match the simulator to the type of car, truck, or SUV utilized by each patient.

When utilizing the car simulator, patients must perform a variety of physical tasks that include approaching the vehicle, opening the car door, getting into proper position for the transfer, turning and lowering themselves into the car seat, bringing their legs into the vehicle, repositioning in the seat if necessary, and buckling the seat belt. One of the more challenging aspects of car transfers is the management of assistive devices during the transfer. Patients who are learning to get in and out of a vehicle often need and depend upon assistive devices, but find that there is limited space between the car door and seat. They require instruction from a skilled therapist for proper placement and utilization of devices such as wheelchairs, power wheelchairs, walkers, hemi-walkers, canes, sliding boards, crutches, etc. Another aspect of managing those assistive devices is ensuring that the caregiver or family member is trained and able to lift and/or stow the devices in the car. The car simulator has behind-seat space specifically designed for practicing this skill. Caregiver training for proper body mechanics will help prevent both injury and broken equipment.

The simulator also has the ability to assess the driver’s brake reaction speed with a reaction time tester. Drivers are given instructions to attend to an illuminated light box with red and green lights. As the green light changes to red, the timer starts and the patient depresses the brake. Reaction speeds are generated and may be compared to age and gender norms as a means of basic biofeedback to the patient. Information from various studies has revealed that in some patient populations, reaction time is a useful metric in determining when it is appropriate to return to driving.⁵ While this decision is ultimately made jointly by the physician and patient, the data generated by the reaction time tester can be valuable information and a means to build insight and confidence for patients and families.

Other elements included in the car transfer/gas station module are an ADA-compliant flooring surface that simulates asphalt, a 6-inch curb typical of those found in parking lots, and a weighted gas pump.

While the benefit of REAL Therapy for patients is clear, the group of people who may be the most invested in REAL Therapy are the rehabilitation clinicians. The amount of time they spend trying to modify the environment to suit the needs of each patient can become direct patient care time. There are also endless possibilities of treatment ideas, so there is less time spent planning and organizing, and more time spent doing. REAL Therapy also removes the necessity of explaining to the patient how the therapy tasks they are doing are applicable to their real-life activities, as the connection is very clear. Rather than moving weights on a shelf to simulate groceries, the patient walks into a grocery store. Rather than move from one chair to another, the patient gets into a car. This immediately makes sense to the patient, increasing their buy-in and willingness to work with therapy.

REAL Therapy is the manifestation of a treatment philosophy that focuses on returning a patient to function. With the move to shorter lengths of stay across all healthcare settings, it is important that physical rehabilitation therapists immediately focus on the patient’s desired activities and begin task-specific training as early as possible. In addition, the evidence base supports functional, task-specific training to achieve better patient outcomes and perceived independence. When used in conjunction with a protocol for therapeutic patient outings into the community, there is an even larger impact on patient confidence and ability. As the rehabilitation industry and we as therapy professionals move forward, REAL Therapy and functional, task-specific treatment may be the key to efficient service delivery and excellent patient outcomes. RM

Tracie Hunnicutt, MS, CCC-SLP, Therapy Manager, received her training as a speech-language pathologist at Texas Tech University Health Sciences Center. The early part of her career was focused on the care of traumatic brain injury (TBI) patients with an emphasis on community re-entry. From this setting, she developed a strong foundation in functional therapy as a tool to return patients back to school, work, community, and home activities. Hunnicutt is currently a medical speech language pathologist in inpatient rehabilitation at HealthSouth Rehabilitation Hospital of Arlington.

Julie Clement, OTR, received her training in occupational therapy at the University of Texas Medical Branch. She specializes in helping patients increase independence with Activities of Daily Living (ADLs), functional mobility, and Instrumental Activities of Daily Living (IADLs). Clement is a Neuro-IFRAH certified therapist, and has completed more than 200 hours of continuing education related to neurological evaluation and treatment. She has been the OT Team Lead at HealthSouth Rehabilitation Hospital of Arlington for the past 12 years.

Susan Adix, PT, received her training as a physical therapist at the University at Buffalo. She began her career in outpatient physical therapy at HealthSouth Arlington, working primarily with orthopedic and neurologic patient populations. In 2006, Adix transitioned into inpatient rehabilitation, where she focused her professional development on the care of neurologic patients. Adix has assisted in the development of the REAL Therapy Gym and is currently the PT Team Lead for a staff of more than 30 physical therapists and rehabilitation techs. For more information, contact RehabEditor@medqor.com.

References

1. Bayona NA, Bitensky J, Salter K, Teasell R. The role of task-specific training in rehabilitation therapies. Top Stroke Rehabil. 2005;12(3):58-65.

2. Brown C, Bradberry C, Howze S, Hickman L, Ray H, Peel C. Defining community ambulation from the perspective of the older adult. J Geriatr Phys Ther. 2010;33:56-53.

3. Elrod C, Bass B, Colvin K. Identification of the key components of car transfers by individuals with dementia. J Geriatr Phys Ther. 2005;28(3):122-123.

4. Haubert LL, Mulroy SJ, Hatchett PE, et al. Car transfer and wheelchair loading techniques in independent drivers with paraplegia. Front Bioeng Biotechnol. 2015 Sep 17;3:139.

5. Dickerson A. Standardizing the RT-2S brake reaction time tester. NewsBrake. 2010;Winter:22-25.

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[Abstract] Cerebrolysin for stroke, neurodegeneration, and traumatic brain injury: review of the literature and outcomes

Abstract

Cerebrolysin therapy has the potential to significantly aid in the treatment of a wide variety of debilitating neurological diseases including ischemic strokes, neurodegenerative disorders, and traumatic brain injuries. Although Cerebrolysin is not approved for use in the USA, it is used clinically in over 50 countries worldwide.

In this review, we focus on outlining the role that Cerebrolysin has in stimulating the molecular signaling pathways that are critical for neurological regeneration and support. An extensive evaluation of these signaling pathways reveals that Cerebrolysin has the potential to intervene in a diverse array of pathophysiological causes of neurological diseases. In the clinical setting, Cerebrolysin is generally safe for human use and has provided functional improvement when used as an adjunct treatment. However, our literature review revealed inconsistent results, as several clinical studies suggested that Cerebrolysin treatment has minor clinical relevance and did not have significant advantages over a placebo.

In conclusion, we found that Cerebrolysin therapy can potentially play a major role in the treatment of many neurological diseases. Nevertheless, there remains much to be elucidated about the efficacy of this treatment for specific neurological conditions, and more robust clinical data is needed to reach a consensus and properly define the therapeutic role of Cerebrolysin.

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[Abstract] Use of Medical Cannabis to Treat Traumatic Brain Injury

Abstract

There is not a single pharmacological agent with demonstrated therapeutic efficacy for traumatic brain injury (TBI). With recent legalization efforts and the growing popularity of medical cannabis, patients with TBI will inevitably consider medical cannabis as a treatment option. Pre-clinical TBI research suggests that cannabinoids have neuroprotective and psychotherapeutic properties. In contrast, recreational cannabis use has consistently shown to have detrimental effects. Our review identified a paucity of high-quality studies examining the beneficial and adverse effects of medical cannabis on TBI, with only a single phase III randomized control trial. However, observational studies demonstrate that TBI patients are using medical and recreational cannabis to treat their symptoms, highlighting inconsistencies between public policy, perception of potential efficacy, and the dearth of empirical evidence. We conclude that randomized controlled trials and prospective studies with appropriate control groups are necessary to fully understand the efficacy and potential adverse effects of medical cannabis for TBI.

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[ARTICLE] Multiplex Networks to Characterize Seizure Development in Traumatic Brain Injury Patients – Full Text

Traumatic brain injury (TBI) may cause secondary debilitating problems, such as post-traumatic epilepsy (PTE), which occurs with unprovoked recurrent seizures, months or even years after TBI. Currently, the Epilepsy Bioinformatics Study for Antiepileptogenic Therapy (EpiBioS4Rx) has been enrolling moderate-severe TBI patients with the goal to identify biomarkers of epileptogenesis that may help to prevent seizure occurrence and better understand the mechanism underlying PTE. In this work, we used a novel complex network approach based on segmenting T1-weighted Magnetic Resonance Imaging (MRI) scans in patches of the same dimension (network nodes) and measured pairwise patch similarities using Pearson’s correlation (network connections). This network model allowed us to obtain a series of single and multiplex network metrics to comprehensively analyze the different interactions between brain components and capture structural MRI alterations related to seizure development. We used these complex network features to train a Random Forest (RF) classifier and predict, with an accuracy of 70 and a 95% confidence interval of [67, 73%], which subjects from EpiBioS4Rx have had at least one seizure after a TBI. This complex network approach also allowed the identification of the most informative scales and brain areas for the discrimination between the two clinical groups: seizure-free and seizure-affected subjects, demonstrating to be a promising pilot study which, in the future, may serve to identify and validate biomarkers of PTE.

1. Introduction

Traumatic brain injury (TBI) is the third most common cause of death and debilitating secondary problems in adults and children worldwide. One common consequence of TBI that causes significant disability amongst patient populations is post-traumatic epilepsy (PTE) (Humphreys et al., 2013). This condition develops in up to 50% of patients with TBI. Post-traumatic epilepsy (PTE) is diagnosed if two or more unprovoked seizures occur at least 1 week after a TBI (Diaz-Arrastia et al., 2009). Recent investigations suggest that injury severity and especially epileptic activity are high risk factors of PTE, although the mechanisms by which trauma to the brain tissue leads to recurrent seizures is not known. Therefore, studying if specific structural Magnetic Resonance Imaging (sMRI) changes can be related to seizures after a TBI is of fundamental importance to carry out the first steps toward the discovery of early biomarkers of PTE (Kim et al., 2018). PTE is not a homogeneous condition and can appear weeks or several years after a TBI. As a consequence, the precise percentage of TBI patients who develop PTE is not known (Verellen and Cavazos, 2010). Currently, growing attention has been devoted to investigate PTE. In this regard, the Epilepsy Bioinformatics Study for Antiepileptogenic Therapy (EpiBioS4Rx) is an international, multi-center project conceived to identify biomarkers of epileptogenesis after a TBI in order to evaluate treatments that could prevent the development of PTE and design clinical trials of antiepileptogenic therapies on an extensive patient population. With this project, the scientific community can be granted access to a large amount of high quality, multi-modal data, including imaging, electrophysiology, and clinical data from both humans and animals.

Changes in gray matter and white matter related to epilepsy have been widely observed by using structural MRI (Immonen et al., 2018; Shah et al., 2019; Lutkenhoff et al., 2020). Many recent studies have shown that machine learning techniques and multiplex networks applied to completely non-invasive neuroimaging techniques, such as structural MRI, can be useful and efficient to detect pathological alterations in several neurological diseases, such as Alzheimer’s disease, Parkinson’s disease, and epilepsy (Amoroso et al., 2018c; La Rocca et al., 2018; Bharath et al., 2019). Multiplex networks overcome the limit of the existing complex network standard approaches not to be able to collectively study what happens to the same nodes as their interactions change. In our previous work (Garner et al., 2019), we used different machine learning strategies to identify alterations in functional brain connectivity that are related to seizure outcome following TBI. However, the present study is the first which uses the combination of multiplex networks of structural MRIs and machine learning techniques to distinguish patients who have developed at least one seizure after a TBI from those who have not experienced any seizures. This study is of paramount importance, because it offers an opportunity to observe alterations in TBI brain networks that may reflect structural MRI changes related to seizure development.

This paper provides three main results: (i) the implementation of a pipeline which combines complex network and machine learning models for the identification of TBI patients who have developed epilepsy; (ii) the investigation of the most appropriate scale or patch size to study seizure development in TBI patients; (iii) the implementation, on a TBI cohort, of a promising complex network model based on segmenting the brain in patches to obtain comprehensive clinical information on the whole brain. In the future, this pilot study may help clinicians localize the epileptogenic focus more precisely, relate brain lesions to seizure occurrence and understand the relationship between neuronal activity abnormalities and structural damage.[…]

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Figure 1. Description of the complex network pipeline and machine learning pipeline. First each subject scan is preprocessed, segmented into patches, then for each subject a weighted undirected network was built and some complex network features were computed. Finally, the feature representation (subject × network features), obtained after the removal of null mean and variance features and highly correlated features, was used as input for the classification pipeline. The machine learning pipeline includes 1,000 rounds of cross-validation (CV). In each round the following steps are performed: (i) dataset was stratified; (ii) 80% of the stratified dataset was used as training set and 20% as validation set; (iii) training set was used, through a first nested Random Forest (RF) classifier, to select the most important features for the discrimination of seizure-free and seizure affected subjects: (iv) these selected features were used in turn to train a second RF classifier; (v) the important features and the classification models obtained on the training test were used to classify the subjects of the validation set; (vi) Averaging the classification performances over the 1,000 CV rounds, we obtained the final accuracy sensitivity, specificity, area under the receiver operating characteristics curve (AUC) and confidence interval on the validation test.

[Abstract] Functional Change from Five to Fifteen Years after Traumatic Brain Injury

Abstract

Few studies have assessed the long-term functional outcomes of traumatic brain injury (TBI) in large, well-characterized samples. Using the Traumatic Brain Injury Model Systems cohort, this study assessed the maintenance of independence between years 5 and 15 post-injury and risk factors for decline. The study sample included 1381 persons with TBI who received inpatient rehabilitation, survived to 15 years post-injury, and were available for data collection at 5 or 10 years and 15 years post-injury. The Functional Independence Measure (FIM) and Disability Rating Scale (DRS) were used to measure functional outcomes. The majority of participants had no changes during the 10-year time frame. For FIM, only 4.4% showed decline in Self-Care, 4.9% declined in Mobility, and 5.9% declined in Cognition. Overall, 10.4% showed decline in one or more FIM subscales. Decline was detected by DRS Level of Function (24% with >1-point change) and Employability (6% with >1-point change). Predictors of decline factors across all measures were age >25 years and, across most measures, having less than or equal to a high school education. Additional predictors of FIM decline included male sex (FIM Mobility and Self-Care) and longer rehabilitation length of stay (FIM Mobility and Cognition). In contrast to studies reporting change in the first 5 years post-TBI inpatient rehabilitation, a majority of those who survive to 15 years do not experience functional decline. Aging and cognitive reserve appear to be more important drivers of loss of function than original severity of the injury. Interventions to identify those at risk for decline may be needed to maintain or enhance functional status as persons age with a TBI.

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