Journal of Head Trauma Rehabilitation最新文献

Objectives: We investigated the acoustic startle reflex in recently concussed adolescent athletes compared to healthy controls and those with concussion history (>1 year prior) but no current symptoms. We hypothesized that individuals with recent concussion would have a suppressed startle response compared to healthy controls.

Methods: We conducted a cross-sectional study on 49 adolescent athletes with a recent concussion (n = 20; age: 14.6 ± 1.6 years; 60% female), a concussion history > 1 year prior (n = 16; age: 14.8 ± 2.0 years; 44% female), and healthy controls (n = 13; age: 13.3 ± 2.8 years; 54% female). We measured the eyeblink of the general startle reflex via electromyography activity of the orbicularis oculi muscle using electrodes placed under the right eye. Measurement sessions included twelve 103 decibel acoustic startle probes ~50 milliseconds in duration delivered ~15-25 seconds apart. The primary dependent variable was mean startle magnitude (µV), and group was the primary independent variable. We used a one-way analysis of variance followed by a Tukey post hoc test to compare mean startle magnitude between groups.

Results: Mean startle magnitude significantly differed (F = 5.49, P = .007) among the groups. Mean startle magnitude was significantly suppressed for the concussion ( P = .01) and concussion history groups ( P = .02) compared to healthy controls. There was no significant difference between the recent concussion and concussion history groups ( P = 1.00).

Conclusion: Our results provide novel evidence for startle suppression in adolescent athletes following concussion. The concussion history group had an attenuated startle response beyond resolution of their recovery, suggesting there may be lingering physiological dysfunction.

Objective: Examine whether concussion mechanism of injury (high-level blast [HLB] vs impact) affects the likelihood of persistent sleep problems in a post-deployment military population.

Setting: Post-Deployment Health Assessment and Re-Assessment survey records completed upon return from deployment and approximately 6 months later.

Participants: Active duty enlisted US Marines who completed both assessments ( N = 64 464).

Design: This retrospective cohort study investigated US Marines deployed between 2008 and 2012. Logistic regression was used to examine persistent sleep problems 6 months after return from deployment.

Main measures: Self-reported sleep problems at reassessment were investigated as the outcome. Predictors included HLB-induced concussions (mbTBI vs none), impact-induced concussions (miTBI vs none), occupational risk of low-level blast, probable posttraumatic stress disorder (PTSD), depression, alcohol misuse, sleep problems upon deployment return, and relevant interactions, adjusting for sex and pay grade.

Results: With the exception of sex, all main effects in the model were associated with greater likelihood of reporting persistent sleep problems at reassessment. Sleep problems at return from deployment showed the strongest associations with likelihood of reporting sleep problems at reassessment, followed by mbTBI. The latter was exacerbated by PTSD and depression.

Conclusion: mbTBI (vs miTBI) may be more strongly associated with persistent sleep issues that warrant additional monitoring and treatment, particularly among those with probable PTSD and/or depression.

Objective: To further evaluate, using quasi-experimental methodologies, posthospital brain injury rehabilitation outcomes described in an accompanying report of a large observational study ( n = 2120).

Setting: Data from Intensive Rehabilitation (IR: Residential Neurobehavioral, Residential Neurorehabilitation, Home and Community Neurorehabilitation, Day Treatment, Outpatient Neurorehabilitation) and Supported Living (SL) programs serving individuals with acquired brain injury (ABI).

Participants: Two hundred twenty-eight individuals with traumatic brain injury, stroke, or other ABI in propensity score analysis; 1344 in analysis by extent of recommended treatment completed (TC) rating.

Main measures: Sex, age, time since injury, Mayo-Portland Adaptability Inventory-4th edition (MPAI-4) Rasch-derived T-scores, and TC rating.

Design: Analyses of covariance (1) of discharge MPAI-4 Total, index, and subscale T-scores on propensity score-matched samples of IR and SL participants controlling for admission scores and (2) of MPAI-4 T-scores by TC rating and diagnostic category.

Results: Propensity score-matched groups showed superior outcomes for IR participants compared to SL participants on MPAI-4 Total T-score ( F = 77.21, P < .001; partial η 2  = 0.257) and all MPAI-4 index and subscale T-scores controlling for sex, age, and baseline scores. Participants with traumatic brain injury and stroke who completed the recommended course of rehabilitation had superior outcomes on all MPAI-4 T-scores compared to those who completed less than or much less than the recommended treatment. No additional benefit was apparent for those who completed more than the recommended course. The association between TC rating and outcome was not significant for the other ABI group.

Conclusions: These analyses using quasi-experimental controls provide more scientifically rigorous evidence of the benefit of IR provided through posthospital brain injury rehabilitation programs after acute inpatient care, consistent with the results of numerous observational studies. However, improved internal validity limits external validity and generalization. The absence of a significant association between TC rating and outcomes for the other ABI group most likely reflects the difficulty prescribing rehabilitation for this highly heterogeneous group.

Objective: Determine the association of inflammatory biomarkers with clinical measures and recovery in participants with concussion.

Setting: Multicenter study in National Collegiate Athletic Association member institutions including military service academies.

Participants: Four hundred twenty-two participants with acute concussion.

Design: Clinical visits and blood draws were completed preinjury and at multiple visits postconcussion (0-12 hours, 12-36 hours, and 36-60 hours postinjury). Clinical measures included Sport Concussion Assessment Tool (SCAT) symptom severity, Balance Error Scoring System, Standardized Assessment of Concussion (SAC), Brief Symptom Inventory-18 (BSI-18) scores, time to initiation of graduated return-to-play (RTP) protocol, and time to RTP. Interleukin (IL)-6, IL-10, IL-8, IL-1 receptor antagonist (RA), tumor necrosis factor (TNF), c-reactive protein, and vascular endothelial growth factor (VEGF) were measured in serum. Prespecified analyses focused on IL-6 and IL-1RA at 0 to 12 hours; exploratory analyses were conducted with false discovery rate correction.

Results: For prespecified analyses, IL-1RA at 0 to 12 hours in female participants was positively associated with more errors on the SAC (B(standard error, SE) = 0.58(0.27), P < .05) and worse SCAT symptom severity (B(SE) = 0.96(0.44), P < .05). For exploratory analyses, higher levels of IL-1RA at 12 to 36 hours were associated with higher global (B(SE) = 0.55(0.14), q < 0.01), depression (B(SE) = 0.45(0.10), q < 0.005), and somatization scores on the BSI (B(SE) = 0.46(0.12), q < 0.01) in participants with concussion; Higher TNF at 12 to 36 hours was associated with fewer errors on the SAC (B(SE) = - 0.46(0.14), q < 0.05). Subanalyses showed similar results for male participants and participants who were athletes. No associations were discovered in nonathlete cadets. Higher IL-8 at 0 to 12 hours was associated with slower RTP in female participants (OR = 14.47; 95% confidence interval, 2.96-70.66, q < 0.05); no other associations with recovery were observed.

Conclusions: Peripheral inflammatory markers are associated with clinical symptoms following concussion and potentially represent one mechanism for psychological symptoms observed postinjury. Current results do not provide strong support for a potential prognostic role for these markers.

Objective: Evaluate compliance, symptom reactivity, and acceptability/experience ratings for an ecological momentary assessment (EMA) protocol involving ultra-brief ambulatory cognitive assessments in adolescent and young adult patients with concussion.

Setting: Outpatient concussion clinic.

Participants: 116 patients aged 13 to 25 years with concussion.

Design: Prospective research design was used to examine compliance, symptom reactivity, and acceptability/experience for the Mobile Neurocognitive Health Project (MNCH); an EMA study of environmental exposures, symptoms, objective cognitive functioning, and symptom reactivity involving 4, daily EMA surveys (7:30 am , 10:30 am , 3:00 pm , 8:00 pm ) for a period of 7 days following concussion. Overall compliance rates, symptom reactivity scores, and participant acceptability/experience ratings were described. A series of non-parametric Friedman Tests with post-hoc Wilcoxon signed-rank tests were used to examine differences in compliance and reactivity related to time of day and over the course of the protocol (first 3 days [Early Week] vs last 4 days [Late Week]).

Main measures: Compliance rates, symptom reactivity scores, participant experience/acceptability.

Results: Overall median compliance was 71%, and there were significantly fewer 7:30 am surveys completed compared to the 10:30 am ( Z = -4 .88, P ≤ .001), 3:00 pm ( Z = -4 .13, P ≤ .001), and 8:00 pm ( Z = -4 .68, P ≤ .001) surveys. Compliance for Early Week surveys were significantly higher than Late Week ( Z = -2 .16, P = .009). The median symptom reactivity score was 34.39 out of 100 and was significantly higher for Early Week compared to Late Week ( Z = -4 .59, P ≤ .001). Ninety-nine percent (89/90) of the sample agreed that the app was easy to use, and 18% (16/90) indicated that the app interfered with their daily life.

Conclusion: Adolescents and young adults with concussion were compliant with the MNCH EMA protocol. Symptom reactivity to the protocol was low and the majority of participants reported that the app and protocol were acceptable. These findings support further investigation into applications of EMA for use in concussion studies.

Objective: To investigate the feasibility, acceptability, and clinical outcome measures of a transitional care intervention for patients with traumatic brain injury (TBI) and their family caregivers.

Setting: Inpatient and outpatient rehabilitation at a level I trauma center in the Southeastern United States.

Participants: Patients (ages 18-75) diagnosed with moderate to severe TBI, receiving rehabilitation, and their family caregivers.

Design: Quasi-experimental, single-arm, single-center feasibility study with pre- and post-test design. Participants completed a 4-month transitional care program involving monthly education and social support.

Main measures: Feasibility of enrollment, data collection, intervention completion rates, and intervention acceptability. Clinical outcome measures included patient quality of life (QOL) (12-Item Short Form Health Survey (SF-12), primary outcome) and patient and caregiver self-efficacy (Self-Efficacy for Management of Chronic Conditions Scale).

Results: Eleven dyads and 1 monad enrolled (N = 23, 12 patients, 11 caregivers). All completed baseline data; 91.3% (n = 21, 11 patients, 10 caregivers) completed 2-month (intervention midpoint) data; and 86% (n = 20, 11 patients, 9 caregivers) completed 4-month (intervention endpoint) data. The intervention completion rate was 91.67%. Participants engaged in a mean of 2.17 (SD = 1.34) monthly educational webinars and 2.42 (SD = 1.51) social support groups during the intervention period. Approximately 70% of participants (n = 16, 9 patients, 7 caregivers) completed acceptability data, indicating positive intervention experiences (patients: mean 9.44/10 [SD = 1.01]; caregivers: mean 9.57/10 [SD = 0.79]). Patient QOL scores did not statistically improve over time; however, patient self-efficacy scores did statistically significantly improve from baseline (mean = 7.03, SD = 1.53; P = .0197) to intervention end point (4 months) (mean = 8.35, SD = 1.71).

Conclusion: Brain Injury Support To Optimize Recovering Minds (BrainSTORM) is a promising new TBI transitional care intervention that has potential to enhance care standards for patients with TBI and their family caregivers. Further research is needed to determine its efficacy.

Objectives: (1) To determine the proportion of participants admitted to supported community living (SCL) programs over the course of 5 years who improve, decline, or maintain functioning and community integration and (2) to examine the associations of time since injury, time in program, and age to their functional trajectory.

Setting: Data from SCL programs serving individuals with acquired brain injury (ABI).

Participants: 104 individuals with traumatic brain injury (TBI), stroke, or other ABI.

Main measures: Sex, age, time since injury, Mayo-Portland Adaptability Inventory (4th edition; MPAI-4).

Design: Retrospective analyses of MPAI-4 total and MPAI-4 indices using Linear Mixed Models (LMM) of Rasch-derived T-scores from admission to 5 years into service delivery.

Results: MPAI-4 total, index, and subscale scores for yearly intervals of SCL services from admission to 5 years showed a high degree of stability in function (defined using the standard error of measurement (SEM) for the MPAI-4, defined as change ≥3 T-score points) with all intervals showing at least 89% of patients with improved scores or no change. The rate of change over time did not significantly vary by time since injury, time in the program, or age.

Conclusions: The expectations for services in the SCL portion of the care continuum for ABI are unique. Unlike intensive rehabilitation programs which focus on improvement often earlier in the course of recovery, the goal of SCL services is sustained functioning over the long term. Analyses reported here indicate this can be achieved for at least 5 years, potentially mitigating the increased risk for rehospitalization and increased care needs in the ABI population. This study highlights a key finding of MPAI-4 stability within these understudied brain injury service lines. Additional exploration of comorbidities and more nuanced delineation of diagnostic information could further clarify factors influencing outcome stability over time.

Objective: To describe the history, organization, goals, and data management procedures of the Foundation to Advance Brain Rehabilitation (FABR).

Setting: Postacute brain injury rehabilitation following acute inpatient care.

Key points: FABR was incorporated in 2019 with a primary mission to advance brain rehabilitation through scientific and strategic analysis of industry-wide data. Contributing FABR member organizations include Bancroft NeuroRehab, Collage Rehabilitation Partners, On With Life, Pate NeuroRehabilitation, and Shepherd Center. These organizations contribute demographic, admission, discharge, and follow-up data on persons served in 5 types of intensive posthospital brain injury rehabilitation programs (neurobehavioral residential, neurorehabilitation residential, home and community neurorehabilitation, day treatment, and outpatient) and 3 types of supported living programs (neurobehavioral residential, residential, and community-based) to a collaborative database managed by Inventive Software Solutions. Inventive Software Solutions provides FABR researchers with a dataset that is de-identified both for participant and organizational identifying information.

Objectives: To identify predictors of moderate to vigorous physical activity (MVPA) at 12-months post-moderate-severe traumatic brain injury (TBI).

Setting: Four inpatient rehabilitation centers.

Participants: Individuals enrolled in the TBI Model Systems with moderate to severe TBI, admitted to inpatient rehabilitation, and able to ambulate without physical assistance from another person.

Design: Prospective longitudinal cohort study. MVPA was measured by having participants wear an ActiGraph GT3X on their wrist for 7 consecutive days.

Main analyses: We used multivariate regression to predict minutes per week of MVPA at 12 months after TBI. Three classes of predictors were entered hierarchically-demographic and clinical variables (age, sex, body mass index, education, TBI severity, neighborhood walkability score, and self-reported preinjury physical activity [PA] level), baseline TBI-related comorbid conditions (eg, measures of sleep, pain, mood, fatigue, and cognition), and intention to exercise and exercise self-efficacy assessed approximately 1 week after discharge from inpatient rehabilitation.

Results: 180 participants (ages 17.7-90.3 years) were enrolled, and 102 provided at least 5 days of valid accelerometer data at 12 months. At 12 months, participants recorded an average of 703 (587) minutes per week of MVPA. In univariate and multivariate analyses, age was the only significant predictor of 12-month MVPA ( r = -0.52). A sharp decline in MVPA was observed in the tertile of participants who were over the age of 61.

Conclusions: Older adults with TBI are at elevated risk of being physically inactive. Assuming PA may enhance health after TBI, older adults are a logical target for prevention or early intervention studies. Studies with longer outcomes are needed to understand the trajectory of PA levels after TBI.

Objective: Persons with traumatic brain injury (TBI) frequently experience emotional distress (ED) manifested in anxiety and depression. However, they may not access mental health services due to external (eg, access, transportation, and cost) or internal (eg, stigma and discomfort with traditional counseling) barriers. Based on substantial literature indicating that self-monitoring can ameliorate several health conditions, we conducted a randomized, parallel group, wait-list control (WLC) trial of a self-monitoring intervention to decrease ED after TBI.

Setting: Community in the southwestern United States.

Participants: Persons with medically documented complicated mild, moderate, and severe TBI.

Design: About 127 participants were randomized in blocks of 6 to an active treatment (AT) group, wherein they completed multiple assessments of ED each week over a 6-week period via a smartphone app, or a WLC group in a parallel group, controlled trial. Participants received weekly support calls to promote self-monitoring of ED using ecological momentary assessment.

Main measures: ED (Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7), Satisfaction with Life Scale, and Participation Assessment with Recombined Tools-Objective.

Results: Analysis of the primary study outcome at 6 weeks after initiation of treatment for the AT group did not demonstrate that self-monitoring was effective in decreasing ED as compared to the WLC group. Brief support calls made weekly to promote compliance with self-monitoring were effective in achieving the target number of self-assessments. About 80% of support calls lasted less than 5 minutes. Greater ED was associated with lower life satisfaction and lower participation indicating the importance of addressing ED in persons with TBI.

Conclusion: Additional work is needed to develop nontraditional interventions to circumvent barriers that prevent persons with TBI from accessing care for ED. Brief support calls may be an effective, low-cost intervention to improve compliance with self-monitoring or self-management interventions.