User login
Vestibular/oculomotor component of concussion warrants more attention
NEW ORLEANS – Vestibular and oculomotor impairment is increasingly recognized as a common, underappreciated, and yet treatable aspect of sports concussions, Gary W. Dorshimer, MD, said at the annual meeting of the American College of Physicians.
A major advance in the diagnosis and treatment of this form of impairment has been achieved by researchers at the University of Pittsburgh Medical Center sports medicine concussion program.
“The Pitt group has come up with a nice exam to assess this part of the concussion injury, which doesn’t affect your memory, it doesn’t affect your cognition, it affects what I’ve found to be the thing that takes the longest to get better: the oculomotor/vestibular mechanism,” explained Dr. Dorshimer, chief of general internal medicine at Penn Medicine, Philadelphia, and team physician for the Philadelphia Flyers professional ice hockey team.
The exam, which the Pitt group has described in full detail (Am J Sports Med. 2014;42(10):2479-86), is known as the Vestibular/Ocular Motor Screening assessment, or VOMS. The tool has filled an unmet need in sports medicine, he said. It takes only a few minutes for a physician to perform. The rating scale assesses visual motion sensitivity, smooth eye pursuits, horizontal and vertical saccades, the vestibular ocular reflex, and convergence. Positive findings warrant specialized referral for targeted rehabilitation using visual-ocular and vestibular therapies.
The symptoms of sports concussion–related oculomotor/vestibular impairment may include nausea, vertigo, dizziness, blurred or double vision, difficulty tracking a moving target, and discomfort in busy environments. These symptoms often translate to difficulty reading and academic problems, which historically often were misinterpreted as cognitive impairments.
It’s estimated that oculomotor/vestibular impairment occurs in roughly 60% of sports concussions. These vestibular and/or vision symptoms are associated with protracted recovery. And preliminary evidence demonstrates that targeted physical therapies are effective in speeding recovery.
“It’s so important to be able to find this [impairment] because it’s something you can do something about. We find that when these things are off and people work on them, they get better. That’s why so many people in the field are now saying that if a patient works hard, does the rehabilitation, the majority of them are going to get better. And they won’t get better unless they press forward,” the internist said.
The VOMS screen is simple to perform. It entails tasks such as convergence testing, in which the physician moves a finger or pen steadily closer to the patient’s face; if the patient reports that the single object has turned into two at a distance of more than 6 cm, that’s a positive result indicative of convergence insufficiency.
In another task, the physician hold his two index fingers apart and has the patients move their eyes from finger to finger while holding their heads still.
“I’m not that interested in whether they’re catching the tips of fingers, I’m interested in if they can go fast, and can they go faster if I challenge them, or do they stop doing it? When people with ocular vestibular dysfunction start doing this task, they’re going to slow down. They can’t keep it up because it’s so unpleasant. It really bothers them a lot,” Dr. Dorshimer observed.
In his experience, another key element in a smooth and successful recovery from sports concussions, in addition to getting skilled help for vestibular/oculomotor impairment, if present, is to encourage a positive attitude.
“If you think you’re going to get CTE [chronic traumatic encephalopathy] when you get older because you got waffled a bit in sport, that’s just such a negative attitude. I mean, you can’t lie to them: We don’t know. But I take care of a ton of retired athletes who don’t have CTE. Maybe they’re going to have some tangles in their brains, but they don’t have it clinically. So you want them to keep a positive attitude,” he emphasized.
“CTE was around when your parents and grandparents were jocks. They went out on the playground and pummeled each other every day after school. There are probably all kinds of factors involved in CTE: the number of concussions, hereditary factors, alcohol, drugs. No one really knows yet,” he said.
Dr. Dorshimer reported having no financial conflicts regarding his presentation on the athlete as patient.
NEW ORLEANS – Vestibular and oculomotor impairment is increasingly recognized as a common, underappreciated, and yet treatable aspect of sports concussions, Gary W. Dorshimer, MD, said at the annual meeting of the American College of Physicians.
A major advance in the diagnosis and treatment of this form of impairment has been achieved by researchers at the University of Pittsburgh Medical Center sports medicine concussion program.
“The Pitt group has come up with a nice exam to assess this part of the concussion injury, which doesn’t affect your memory, it doesn’t affect your cognition, it affects what I’ve found to be the thing that takes the longest to get better: the oculomotor/vestibular mechanism,” explained Dr. Dorshimer, chief of general internal medicine at Penn Medicine, Philadelphia, and team physician for the Philadelphia Flyers professional ice hockey team.
The exam, which the Pitt group has described in full detail (Am J Sports Med. 2014;42(10):2479-86), is known as the Vestibular/Ocular Motor Screening assessment, or VOMS. The tool has filled an unmet need in sports medicine, he said. It takes only a few minutes for a physician to perform. The rating scale assesses visual motion sensitivity, smooth eye pursuits, horizontal and vertical saccades, the vestibular ocular reflex, and convergence. Positive findings warrant specialized referral for targeted rehabilitation using visual-ocular and vestibular therapies.
The symptoms of sports concussion–related oculomotor/vestibular impairment may include nausea, vertigo, dizziness, blurred or double vision, difficulty tracking a moving target, and discomfort in busy environments. These symptoms often translate to difficulty reading and academic problems, which historically often were misinterpreted as cognitive impairments.
It’s estimated that oculomotor/vestibular impairment occurs in roughly 60% of sports concussions. These vestibular and/or vision symptoms are associated with protracted recovery. And preliminary evidence demonstrates that targeted physical therapies are effective in speeding recovery.
“It’s so important to be able to find this [impairment] because it’s something you can do something about. We find that when these things are off and people work on them, they get better. That’s why so many people in the field are now saying that if a patient works hard, does the rehabilitation, the majority of them are going to get better. And they won’t get better unless they press forward,” the internist said.
The VOMS screen is simple to perform. It entails tasks such as convergence testing, in which the physician moves a finger or pen steadily closer to the patient’s face; if the patient reports that the single object has turned into two at a distance of more than 6 cm, that’s a positive result indicative of convergence insufficiency.
In another task, the physician hold his two index fingers apart and has the patients move their eyes from finger to finger while holding their heads still.
“I’m not that interested in whether they’re catching the tips of fingers, I’m interested in if they can go fast, and can they go faster if I challenge them, or do they stop doing it? When people with ocular vestibular dysfunction start doing this task, they’re going to slow down. They can’t keep it up because it’s so unpleasant. It really bothers them a lot,” Dr. Dorshimer observed.
In his experience, another key element in a smooth and successful recovery from sports concussions, in addition to getting skilled help for vestibular/oculomotor impairment, if present, is to encourage a positive attitude.
“If you think you’re going to get CTE [chronic traumatic encephalopathy] when you get older because you got waffled a bit in sport, that’s just such a negative attitude. I mean, you can’t lie to them: We don’t know. But I take care of a ton of retired athletes who don’t have CTE. Maybe they’re going to have some tangles in their brains, but they don’t have it clinically. So you want them to keep a positive attitude,” he emphasized.
“CTE was around when your parents and grandparents were jocks. They went out on the playground and pummeled each other every day after school. There are probably all kinds of factors involved in CTE: the number of concussions, hereditary factors, alcohol, drugs. No one really knows yet,” he said.
Dr. Dorshimer reported having no financial conflicts regarding his presentation on the athlete as patient.
NEW ORLEANS – Vestibular and oculomotor impairment is increasingly recognized as a common, underappreciated, and yet treatable aspect of sports concussions, Gary W. Dorshimer, MD, said at the annual meeting of the American College of Physicians.
A major advance in the diagnosis and treatment of this form of impairment has been achieved by researchers at the University of Pittsburgh Medical Center sports medicine concussion program.
“The Pitt group has come up with a nice exam to assess this part of the concussion injury, which doesn’t affect your memory, it doesn’t affect your cognition, it affects what I’ve found to be the thing that takes the longest to get better: the oculomotor/vestibular mechanism,” explained Dr. Dorshimer, chief of general internal medicine at Penn Medicine, Philadelphia, and team physician for the Philadelphia Flyers professional ice hockey team.
The exam, which the Pitt group has described in full detail (Am J Sports Med. 2014;42(10):2479-86), is known as the Vestibular/Ocular Motor Screening assessment, or VOMS. The tool has filled an unmet need in sports medicine, he said. It takes only a few minutes for a physician to perform. The rating scale assesses visual motion sensitivity, smooth eye pursuits, horizontal and vertical saccades, the vestibular ocular reflex, and convergence. Positive findings warrant specialized referral for targeted rehabilitation using visual-ocular and vestibular therapies.
The symptoms of sports concussion–related oculomotor/vestibular impairment may include nausea, vertigo, dizziness, blurred or double vision, difficulty tracking a moving target, and discomfort in busy environments. These symptoms often translate to difficulty reading and academic problems, which historically often were misinterpreted as cognitive impairments.
It’s estimated that oculomotor/vestibular impairment occurs in roughly 60% of sports concussions. These vestibular and/or vision symptoms are associated with protracted recovery. And preliminary evidence demonstrates that targeted physical therapies are effective in speeding recovery.
“It’s so important to be able to find this [impairment] because it’s something you can do something about. We find that when these things are off and people work on them, they get better. That’s why so many people in the field are now saying that if a patient works hard, does the rehabilitation, the majority of them are going to get better. And they won’t get better unless they press forward,” the internist said.
The VOMS screen is simple to perform. It entails tasks such as convergence testing, in which the physician moves a finger or pen steadily closer to the patient’s face; if the patient reports that the single object has turned into two at a distance of more than 6 cm, that’s a positive result indicative of convergence insufficiency.
In another task, the physician hold his two index fingers apart and has the patients move their eyes from finger to finger while holding their heads still.
“I’m not that interested in whether they’re catching the tips of fingers, I’m interested in if they can go fast, and can they go faster if I challenge them, or do they stop doing it? When people with ocular vestibular dysfunction start doing this task, they’re going to slow down. They can’t keep it up because it’s so unpleasant. It really bothers them a lot,” Dr. Dorshimer observed.
In his experience, another key element in a smooth and successful recovery from sports concussions, in addition to getting skilled help for vestibular/oculomotor impairment, if present, is to encourage a positive attitude.
“If you think you’re going to get CTE [chronic traumatic encephalopathy] when you get older because you got waffled a bit in sport, that’s just such a negative attitude. I mean, you can’t lie to them: We don’t know. But I take care of a ton of retired athletes who don’t have CTE. Maybe they’re going to have some tangles in their brains, but they don’t have it clinically. So you want them to keep a positive attitude,” he emphasized.
“CTE was around when your parents and grandparents were jocks. They went out on the playground and pummeled each other every day after school. There are probably all kinds of factors involved in CTE: the number of concussions, hereditary factors, alcohol, drugs. No one really knows yet,” he said.
Dr. Dorshimer reported having no financial conflicts regarding his presentation on the athlete as patient.
REPORTING FROM ACP INTERNAL MEDICINE
How Does TBI Differ Among Older Patients?
LOS ANGELES—Most older adults recover well from traumatic brain injury (TBI), according to research presented at the 70th Annual Meeting of the American Academy of Neurology. Compared with younger patients, older adults endorse less independence after injury, but are less likely to report TBI-related neurobehavioral symptoms. A greater burden of preinjury disability among the elderly may explain these apparently conflicting results, according to the researchers.
Geriatric TBI is “a silent and growing epidemic,” said Raquel Gardner, MD, Assistant Professor of Neurology at the University of California, San Francisco. Older adults have the highest incidence of TBI-related emergency department visits, hospitalizations, and deaths, according to 2013 data from the CDC. Most research has indicated that this population has worse outcomes of TBI than younger populations do. Few studies, however, have examined age-related differences in neurobehavioral outcomes of TBI.
Injury Was More Severe Among Older Patients
To address this gap in the literature, Dr. Gardner and colleagues examined data from the TRACK-TBI pilot study. Eligible patients presented to participating trauma centers within 24 hours of sustaining a TBI that was severe enough to warrant head CT. The TRACK-TBI study excluded participants with a diagnosis of dementia or any pre-existing condition that would impair their ability to complete outcome assessments. Patients’ neurobehavioral outcomes were evaluated prospectively with measures such as the Glasgow Outcome Scale Extended (GOSE), Craig Handicap Assessment and Reporting Technique-Short Form (CHART-SF), Brief Symptom Inventory (BSI-18), Rivermead Post-Concussion Questionnaire (RPQ), Posttraumatic Stress Disorder Checklist-Civilian (PCL-C), and the Satisfaction With Life Scale (SWLS). 
Dr. Gardner and colleagues categorized 586 patients as young (ie, younger than 40), middle-aged (ie, ages 40 to 59), or older (ie, age 60 or older). They compared baseline features and six-month neurobehavioral outcomes between the three groups using χ2, analysis of variance, and regression modeling.
Patients’ age ranged from 16 to 94. At baseline, the prevalence of female sex and white race increased with increasing age. Older adults were less likely to report a prior history of TBI than the other two age groups. TBI resulted from a fall for most older patients. At presentation, Glasgow Coma Scale scores did not differ significantly between the three patient groups, and older adults were less likely to report having experienced loss of consciousness or posttraumatic amnesia than the other groups.
Injury was more severe among older patients, however, as assessed by the Acute Injury Scale, the Injury Severity Scale, and CT pathology, compared with younger participants. Older patients also were more likely to be admitted to the intensive care unit.
Measures May Not Be Age-Appropriate
At six months, 415 of the participants completed the GOSE. The mortality rate was approximately 18% among older patients, compared with 7% among middle-aged patients and less than 1% among young patients. Among older patients who survived to six months, most achieved a good recovery, which was defined as a GOSE score of 7 to 8. After the researchers adjusted the data for baseline demographic differences, the rate of good recovery was not significantly different between the three age groups.
Older patients reported significantly less anxiety than other patients, as measured by the BSI-18. Older patients tended to report fewer symptoms overall on the BSI-18 and the RPQ, compared with the other groups. In addition, older patients reported fewer symptoms of PTSD and less dissatisfaction with life, compared with the other groups.
CHART-SF scores, however, were worse overall among older patients, said Dr. Gardner. Although they indicated better economic outcomes among older patients, compared with the other age groups, they also indicated less independence among older patients. Cognition and mobility in particular were worse among older patients than among the other groups.
Older patients were more likely to complete the GOSE than younger patients, but less likely to complete other assessments. The differences in response rates could create a misleadingly positive impression of six-month outcomes among older patients, said Dr. Gardner.
One interpretation of the results is that measures that are not age-appropriate are causing older patients to underreport TBI symptoms, she added. Survival bias also may partly explain the positive six-month outcomes. “We need studies that are truly representative of the entire geriatric TBI population and systematically measure, rather than exclude for, this huge heterogeneity in preinjury disability,” said Dr. Gardner. Investigators should take steps “to optimize enrollment, optimize retention, and optimize outcome completion in a frail and burdened population. We need to ultimately develop consensus NINDS geriatric TBI common data elements…. Only then can we unravel predictors of meaningful recovery in this vulnerable population, develop age-appropriate treatment guidelines, and improve outcomes.”
—Erik Greb
Suggested Reading
Yue JK, Winkler EA, Sharma S, et al. Temporal profile of care following mild traumatic brain injury: predictors of hospital admission, follow-up referral and six-month outcome. Brain Inj. 2017;31(13-14):1820-1829.
LOS ANGELES—Most older adults recover well from traumatic brain injury (TBI), according to research presented at the 70th Annual Meeting of the American Academy of Neurology. Compared with younger patients, older adults endorse less independence after injury, but are less likely to report TBI-related neurobehavioral symptoms. A greater burden of preinjury disability among the elderly may explain these apparently conflicting results, according to the researchers.
Geriatric TBI is “a silent and growing epidemic,” said Raquel Gardner, MD, Assistant Professor of Neurology at the University of California, San Francisco. Older adults have the highest incidence of TBI-related emergency department visits, hospitalizations, and deaths, according to 2013 data from the CDC. Most research has indicated that this population has worse outcomes of TBI than younger populations do. Few studies, however, have examined age-related differences in neurobehavioral outcomes of TBI.
Injury Was More Severe Among Older Patients
To address this gap in the literature, Dr. Gardner and colleagues examined data from the TRACK-TBI pilot study. Eligible patients presented to participating trauma centers within 24 hours of sustaining a TBI that was severe enough to warrant head CT. The TRACK-TBI study excluded participants with a diagnosis of dementia or any pre-existing condition that would impair their ability to complete outcome assessments. Patients’ neurobehavioral outcomes were evaluated prospectively with measures such as the Glasgow Outcome Scale Extended (GOSE), Craig Handicap Assessment and Reporting Technique-Short Form (CHART-SF), Brief Symptom Inventory (BSI-18), Rivermead Post-Concussion Questionnaire (RPQ), Posttraumatic Stress Disorder Checklist-Civilian (PCL-C), and the Satisfaction With Life Scale (SWLS).
Dr. Gardner and colleagues categorized 586 patients as young (ie, younger than 40), middle-aged (ie, ages 40 to 59), or older (ie, age 60 or older). They compared baseline features and six-month neurobehavioral outcomes between the three groups using χ2, analysis of variance, and regression modeling.
Patients’ age ranged from 16 to 94. At baseline, the prevalence of female sex and white race increased with increasing age. Older adults were less likely to report a prior history of TBI than the other two age groups. TBI resulted from a fall for most older patients. At presentation, Glasgow Coma Scale scores did not differ significantly between the three patient groups, and older adults were less likely to report having experienced loss of consciousness or posttraumatic amnesia than the other groups.
Injury was more severe among older patients, however, as assessed by the Acute Injury Scale, the Injury Severity Scale, and CT pathology, compared with younger participants. Older patients also were more likely to be admitted to the intensive care unit.
Measures May Not Be Age-Appropriate
At six months, 415 of the participants completed the GOSE. The mortality rate was approximately 18% among older patients, compared with 7% among middle-aged patients and less than 1% among young patients. Among older patients who survived to six months, most achieved a good recovery, which was defined as a GOSE score of 7 to 8. After the researchers adjusted the data for baseline demographic differences, the rate of good recovery was not significantly different between the three age groups.
Older patients reported significantly less anxiety than other patients, as measured by the BSI-18. Older patients tended to report fewer symptoms overall on the BSI-18 and the RPQ, compared with the other groups. In addition, older patients reported fewer symptoms of PTSD and less dissatisfaction with life, compared with the other groups.
CHART-SF scores, however, were worse overall among older patients, said Dr. Gardner. Although they indicated better economic outcomes among older patients, compared with the other age groups, they also indicated less independence among older patients. Cognition and mobility in particular were worse among older patients than among the other groups.
Older patients were more likely to complete the GOSE than younger patients, but less likely to complete other assessments. The differences in response rates could create a misleadingly positive impression of six-month outcomes among older patients, said Dr. Gardner.
One interpretation of the results is that measures that are not age-appropriate are causing older patients to underreport TBI symptoms, she added. Survival bias also may partly explain the positive six-month outcomes. “We need studies that are truly representative of the entire geriatric TBI population and systematically measure, rather than exclude for, this huge heterogeneity in preinjury disability,” said Dr. Gardner. Investigators should take steps “to optimize enrollment, optimize retention, and optimize outcome completion in a frail and burdened population. We need to ultimately develop consensus NINDS geriatric TBI common data elements…. Only then can we unravel predictors of meaningful recovery in this vulnerable population, develop age-appropriate treatment guidelines, and improve outcomes.”
—Erik Greb
Suggested Reading
Yue JK, Winkler EA, Sharma S, et al. Temporal profile of care following mild traumatic brain injury: predictors of hospital admission, follow-up referral and six-month outcome. Brain Inj. 2017;31(13-14):1820-1829.
LOS ANGELES—Most older adults recover well from traumatic brain injury (TBI), according to research presented at the 70th Annual Meeting of the American Academy of Neurology. Compared with younger patients, older adults endorse less independence after injury, but are less likely to report TBI-related neurobehavioral symptoms. A greater burden of preinjury disability among the elderly may explain these apparently conflicting results, according to the researchers.
Geriatric TBI is “a silent and growing epidemic,” said Raquel Gardner, MD, Assistant Professor of Neurology at the University of California, San Francisco. Older adults have the highest incidence of TBI-related emergency department visits, hospitalizations, and deaths, according to 2013 data from the CDC. Most research has indicated that this population has worse outcomes of TBI than younger populations do. Few studies, however, have examined age-related differences in neurobehavioral outcomes of TBI.
Injury Was More Severe Among Older Patients
To address this gap in the literature, Dr. Gardner and colleagues examined data from the TRACK-TBI pilot study. Eligible patients presented to participating trauma centers within 24 hours of sustaining a TBI that was severe enough to warrant head CT. The TRACK-TBI study excluded participants with a diagnosis of dementia or any pre-existing condition that would impair their ability to complete outcome assessments. Patients’ neurobehavioral outcomes were evaluated prospectively with measures such as the Glasgow Outcome Scale Extended (GOSE), Craig Handicap Assessment and Reporting Technique-Short Form (CHART-SF), Brief Symptom Inventory (BSI-18), Rivermead Post-Concussion Questionnaire (RPQ), Posttraumatic Stress Disorder Checklist-Civilian (PCL-C), and the Satisfaction With Life Scale (SWLS).
Dr. Gardner and colleagues categorized 586 patients as young (ie, younger than 40), middle-aged (ie, ages 40 to 59), or older (ie, age 60 or older). They compared baseline features and six-month neurobehavioral outcomes between the three groups using χ2, analysis of variance, and regression modeling.
Patients’ age ranged from 16 to 94. At baseline, the prevalence of female sex and white race increased with increasing age. Older adults were less likely to report a prior history of TBI than the other two age groups. TBI resulted from a fall for most older patients. At presentation, Glasgow Coma Scale scores did not differ significantly between the three patient groups, and older adults were less likely to report having experienced loss of consciousness or posttraumatic amnesia than the other groups.
Injury was more severe among older patients, however, as assessed by the Acute Injury Scale, the Injury Severity Scale, and CT pathology, compared with younger participants. Older patients also were more likely to be admitted to the intensive care unit.
Measures May Not Be Age-Appropriate
At six months, 415 of the participants completed the GOSE. The mortality rate was approximately 18% among older patients, compared with 7% among middle-aged patients and less than 1% among young patients. Among older patients who survived to six months, most achieved a good recovery, which was defined as a GOSE score of 7 to 8. After the researchers adjusted the data for baseline demographic differences, the rate of good recovery was not significantly different between the three age groups.
Older patients reported significantly less anxiety than other patients, as measured by the BSI-18. Older patients tended to report fewer symptoms overall on the BSI-18 and the RPQ, compared with the other groups. In addition, older patients reported fewer symptoms of PTSD and less dissatisfaction with life, compared with the other groups.
CHART-SF scores, however, were worse overall among older patients, said Dr. Gardner. Although they indicated better economic outcomes among older patients, compared with the other age groups, they also indicated less independence among older patients. Cognition and mobility in particular were worse among older patients than among the other groups.
Older patients were more likely to complete the GOSE than younger patients, but less likely to complete other assessments. The differences in response rates could create a misleadingly positive impression of six-month outcomes among older patients, said Dr. Gardner.
One interpretation of the results is that measures that are not age-appropriate are causing older patients to underreport TBI symptoms, she added. Survival bias also may partly explain the positive six-month outcomes. “We need studies that are truly representative of the entire geriatric TBI population and systematically measure, rather than exclude for, this huge heterogeneity in preinjury disability,” said Dr. Gardner. Investigators should take steps “to optimize enrollment, optimize retention, and optimize outcome completion in a frail and burdened population. We need to ultimately develop consensus NINDS geriatric TBI common data elements…. Only then can we unravel predictors of meaningful recovery in this vulnerable population, develop age-appropriate treatment guidelines, and improve outcomes.”
—Erik Greb
Suggested Reading
Yue JK, Winkler EA, Sharma S, et al. Temporal profile of care following mild traumatic brain injury: predictors of hospital admission, follow-up referral and six-month outcome. Brain Inj. 2017;31(13-14):1820-1829.
S100B biomarker could reduce CT scans in children with mTBI
according to Charlotte Oris, PharmD, of the University Hospital of Clermont-Ferrand, France, and her associates.
In a meta-analysis of eight prospective cohort studies including a total of 601 children published in Pediatrics, researchers looked at the association between S100B serum levels and CT findings in 373 patients. The median serum concentrations of S100B were 0.47 mcg/L for patients with intracerebral lesions and 0.21 mcg/L for those without lesions (P less than .001).
Additionally, researchers collected data from 358 individuals included in two studies for the origin of mTBI. The median concentrations of S100B were 0.39 mcg/L for road accidents, 0.29 mcg/L for domestic accidents, and 0.18 mcg/L for sport-related accidents. The difference was statistically significant between the road accidents group and the domestic accidents group (P less than .001) and the difference between the road accidents group and the sport-related accidents group (P less than .001). It is noted that S100B specificity could be higher after a sport-related trauma.
“S100B protein serum levels, in combination with the PECARN [Pediatric Emergency Care Applied Research Network] algorithm, could reduce the need for CT scans by one-third. In our additional analysis, based on 373 children, the importance of taking a blood sample 3 hours or less after trauma was underscored,” the researchers said.
“S100B represents a promising biomarker with 100% sensitivity. The limited specificity of S100B could be reevaluated for future research by using a combination of different brain biomarkers,” Dr. Oris and her colleagues concluded.
SOURCE: Oris C et al. Pediatrics. 2018. doi: 10.1542/peds.2018-0037.
according to Charlotte Oris, PharmD, of the University Hospital of Clermont-Ferrand, France, and her associates.
In a meta-analysis of eight prospective cohort studies including a total of 601 children published in Pediatrics, researchers looked at the association between S100B serum levels and CT findings in 373 patients. The median serum concentrations of S100B were 0.47 mcg/L for patients with intracerebral lesions and 0.21 mcg/L for those without lesions (P less than .001).
Additionally, researchers collected data from 358 individuals included in two studies for the origin of mTBI. The median concentrations of S100B were 0.39 mcg/L for road accidents, 0.29 mcg/L for domestic accidents, and 0.18 mcg/L for sport-related accidents. The difference was statistically significant between the road accidents group and the domestic accidents group (P less than .001) and the difference between the road accidents group and the sport-related accidents group (P less than .001). It is noted that S100B specificity could be higher after a sport-related trauma.
“S100B protein serum levels, in combination with the PECARN [Pediatric Emergency Care Applied Research Network] algorithm, could reduce the need for CT scans by one-third. In our additional analysis, based on 373 children, the importance of taking a blood sample 3 hours or less after trauma was underscored,” the researchers said.
“S100B represents a promising biomarker with 100% sensitivity. The limited specificity of S100B could be reevaluated for future research by using a combination of different brain biomarkers,” Dr. Oris and her colleagues concluded.
SOURCE: Oris C et al. Pediatrics. 2018. doi: 10.1542/peds.2018-0037.
according to Charlotte Oris, PharmD, of the University Hospital of Clermont-Ferrand, France, and her associates.
In a meta-analysis of eight prospective cohort studies including a total of 601 children published in Pediatrics, researchers looked at the association between S100B serum levels and CT findings in 373 patients. The median serum concentrations of S100B were 0.47 mcg/L for patients with intracerebral lesions and 0.21 mcg/L for those without lesions (P less than .001).
Additionally, researchers collected data from 358 individuals included in two studies for the origin of mTBI. The median concentrations of S100B were 0.39 mcg/L for road accidents, 0.29 mcg/L for domestic accidents, and 0.18 mcg/L for sport-related accidents. The difference was statistically significant between the road accidents group and the domestic accidents group (P less than .001) and the difference between the road accidents group and the sport-related accidents group (P less than .001). It is noted that S100B specificity could be higher after a sport-related trauma.
“S100B protein serum levels, in combination with the PECARN [Pediatric Emergency Care Applied Research Network] algorithm, could reduce the need for CT scans by one-third. In our additional analysis, based on 373 children, the importance of taking a blood sample 3 hours or less after trauma was underscored,” the researchers said.
“S100B represents a promising biomarker with 100% sensitivity. The limited specificity of S100B could be reevaluated for future research by using a combination of different brain biomarkers,” Dr. Oris and her colleagues concluded.
SOURCE: Oris C et al. Pediatrics. 2018. doi: 10.1542/peds.2018-0037.
Brain Stimulation May Enhance Memory
Electrical stimulation in the lateral temporal cortex enhances verbal memory performance, according to two studies in patients with epilepsy.
“While electrical stimulation of the brain is emerging as potential therapy for a wide range of neurologic and psychiatric diseases, little is known about its effect on memory,” said Gregory Worrell, MD, PhD, Professor of Neurology at the Mayo Clinic in Rochester, Minnesota, and an author of the studies. Electrical stimulation may have the potential to treat memory deficits and cognitive dysfunction in brain disorders such as traumatic brain injury and Alzheimer’s disease, the researchers said. 
The two studies were part of a multicenter project designed to assess the effects of electrical stimulation on memory-related brain function and were supported by the Defense Advanced Research Projects Agency’s Restoring Active Memory program.
Patients Were Tested During Seizure Monitoring
In the April issue of Brain, Michal T. Kucewicz, PhD, a researcher at the Mayo Clinic, and colleagues described a study of patients with epilepsy who were undergoing evaluation for resective surgery. As part of the evaluations, patients had intracranial subdural and depth electrode arrays implanted in cortical and subcortical brain regions.
After implantation, patients completed delayed free-recall memory tasks in which they learned lists of words for subsequent recall. Twelve words appeared one at a time on a laptop screen for 1.6 seconds each. Participants then solved a series of arithmetic problems. Afterward, participants had 30 seconds to verbally recall as many words as possible from the list in any order. Patients completed this procedure 25 times during each testing session. Twenty of the lists in each session were learned with stimulation (ie, with stimulation applied for two words and then turned off for two words throughout the list), and five lists were learned without stimulation. Participants completed at least two control sessions with no stimulation to reduce potential learning effects.
The investigators focused on 22 patients (nine males) who had electrodes implanted in four brain regions known to support declarative memory: the hippocampus (n = 6), the parahippocampal cortex (n = 7), the prefrontal cortex (n = 6), and the temporal cortex (n = 4). One subject received stimulation in two of the brain regions (ie, the temporal cortex and the parahippocampal cortex).
The number of sessions that patients completed was determined by the length of seizure monitoring (range, two days to 14 days) and patients’ willingness to participate in the study. The subjects were blinded to the stimulation site.
Within-Individual and Between-Group Effects
Stimulation in the lateral temporal cortex enhanced memory performance, whereas stimulation in other brain regions did not. “The positive effect of [lateral cortex] stimulation was reported in individual patients tested across multiple days of stimulation sessions, on the level of the group of patients stimulated in the temporal cortex, and between the four groups stimulated in different brain regions,” the researchers said.
Two of the four patients stimulated in the lateral temporal cortex had significantly improved recall with stimulation, and the other two patients showed a positive trend.
In the subject who received stimulation in two brain regions, stimulation in the dominant lateral temporal neocortex increased the number of remembered words above the normal range, whereas stimulation in the parahippocampal region did not.
Among the participants who received temporal cortex stimulation, memory performance within each session on the stimulated word lists was consistently higher than on the control lists without stimulation.
For the stimulated lists, memory enhancement was observed on the level of the entire list, with no difference in recall between stimulated and nonstimulated words. This finding suggests that the positive effect of stimulation lasted beyond the period of electrical current administration, the researchers said.
The study’s limitations include the small number of participants and their variable clinical characteristics (eg, epilepsy pathologies, medications, and baseline cognition). It is unclear whether electrical stimulation modulates memory processing, attention, perception, or other related processes, the researchers noted. It also is not known whether the positive effect generalizes to other verbal and nonverbal memory functions, or whether stimulation in the nondominant hemisphere would have a different effect.
The data “might provide a hint as to why some patients undergoing surgical removal of this region complain about verbal memory deficits,” Dr. Kucewicz and colleagues said.
“The next step for this project is to determine how to best apply electrical current in terms of the exact location within this area of the brain, timing, and parameters of stimulation,” said study author Brent Berry, MD, PhD, a Mayo Clinic researcher in the Department of Physiology and Biomedical Engineering.
A Closed-Loop Approach
In a study published February 6 in Nature Communications, Youssef Ezzyat, PhD, a senior data scientist at the University of Pennsylvania in Philadelphia, and colleagues found that a closed-loop stimulation system may identify periods of poor memory encoding and apply targeted stimulation to the lateral temporal cortex to compensate.
The investigators recruited 25 neurosurgical patients undergoing clinical monitoring for epilepsy to participate in sessions of a delayed free-recall memory task. Subjects completed at least three record-only sessions of free recall with which the researchers trained a system to use intracranial EEG activity during encoding to predict the likelihood of later word recall.
During subsequent sessions, if the system predicted that the probability of recall was less than 0.5, it triggered 500 ms of bipolar stimulation. The researchers found that lateral temporal cortex stimulation increased the relative probability of item recall by 15%.
“By developing patient-specific, personalized, machine-learning models, we could program our stimulator to deliver pulses only when memory was predicted to fail, giving this technology the best chance of restoring memory function,” said Michael Kahana, PhD, Professor of Psychology at the University of Pennsylvania and principal investigator of the Restoring Active Memory program. “This [approach] was important, because we knew from earlier work that stimulating the brain during periods of good function was likely to make memory worse.”
—Jake Remaly
Suggested Reading
Ezzyat Y, Wanda PA, Levy DF, et al. Closed-loop stimulation of temporal cortex rescues functional networks and improves memory. Nat Commun. 2018;9(1):365.
Hampson RE, Song D, Robinson BS, et al. Developing a hippocampal neural prosthetic to facilitate human memory encoding and recall. J Neural Eng. 2018;15(3):036014.
Inman CS, Manns JR, Bijanki KR, et al. Direct electrical stimulation of the amygdala enhances declarative memory in humans. Proc Natl Acad Sci U S A. 2018;115(1):98-103.
Kucewicz MT, Berry BM, Kremen V, et al. Electrical stimulation modulates high γ activity and human memory performance. eNeuro. 2018;5(1).
Kucewicz MT, Berry BM, Miller LR, et al. Evidence for verbal memory enhancement with electrical brain stimulation in the lateral temporal cortex. Brain. 2018;141(4):971-978.
Electrical stimulation in the lateral temporal cortex enhances verbal memory performance, according to two studies in patients with epilepsy.
“While electrical stimulation of the brain is emerging as potential therapy for a wide range of neurologic and psychiatric diseases, little is known about its effect on memory,” said Gregory Worrell, MD, PhD, Professor of Neurology at the Mayo Clinic in Rochester, Minnesota, and an author of the studies. Electrical stimulation may have the potential to treat memory deficits and cognitive dysfunction in brain disorders such as traumatic brain injury and Alzheimer’s disease, the researchers said.
The two studies were part of a multicenter project designed to assess the effects of electrical stimulation on memory-related brain function and were supported by the Defense Advanced Research Projects Agency’s Restoring Active Memory program.
Patients Were Tested During Seizure Monitoring
In the April issue of Brain, Michal T. Kucewicz, PhD, a researcher at the Mayo Clinic, and colleagues described a study of patients with epilepsy who were undergoing evaluation for resective surgery. As part of the evaluations, patients had intracranial subdural and depth electrode arrays implanted in cortical and subcortical brain regions.
After implantation, patients completed delayed free-recall memory tasks in which they learned lists of words for subsequent recall. Twelve words appeared one at a time on a laptop screen for 1.6 seconds each. Participants then solved a series of arithmetic problems. Afterward, participants had 30 seconds to verbally recall as many words as possible from the list in any order. Patients completed this procedure 25 times during each testing session. Twenty of the lists in each session were learned with stimulation (ie, with stimulation applied for two words and then turned off for two words throughout the list), and five lists were learned without stimulation. Participants completed at least two control sessions with no stimulation to reduce potential learning effects.
The investigators focused on 22 patients (nine males) who had electrodes implanted in four brain regions known to support declarative memory: the hippocampus (n = 6), the parahippocampal cortex (n = 7), the prefrontal cortex (n = 6), and the temporal cortex (n = 4). One subject received stimulation in two of the brain regions (ie, the temporal cortex and the parahippocampal cortex).
The number of sessions that patients completed was determined by the length of seizure monitoring (range, two days to 14 days) and patients’ willingness to participate in the study. The subjects were blinded to the stimulation site.
Within-Individual and Between-Group Effects
Stimulation in the lateral temporal cortex enhanced memory performance, whereas stimulation in other brain regions did not. “The positive effect of [lateral cortex] stimulation was reported in individual patients tested across multiple days of stimulation sessions, on the level of the group of patients stimulated in the temporal cortex, and between the four groups stimulated in different brain regions,” the researchers said.
Two of the four patients stimulated in the lateral temporal cortex had significantly improved recall with stimulation, and the other two patients showed a positive trend.
In the subject who received stimulation in two brain regions, stimulation in the dominant lateral temporal neocortex increased the number of remembered words above the normal range, whereas stimulation in the parahippocampal region did not.
Among the participants who received temporal cortex stimulation, memory performance within each session on the stimulated word lists was consistently higher than on the control lists without stimulation.
For the stimulated lists, memory enhancement was observed on the level of the entire list, with no difference in recall between stimulated and nonstimulated words. This finding suggests that the positive effect of stimulation lasted beyond the period of electrical current administration, the researchers said.
The study’s limitations include the small number of participants and their variable clinical characteristics (eg, epilepsy pathologies, medications, and baseline cognition). It is unclear whether electrical stimulation modulates memory processing, attention, perception, or other related processes, the researchers noted. It also is not known whether the positive effect generalizes to other verbal and nonverbal memory functions, or whether stimulation in the nondominant hemisphere would have a different effect.
The data “might provide a hint as to why some patients undergoing surgical removal of this region complain about verbal memory deficits,” Dr. Kucewicz and colleagues said.
“The next step for this project is to determine how to best apply electrical current in terms of the exact location within this area of the brain, timing, and parameters of stimulation,” said study author Brent Berry, MD, PhD, a Mayo Clinic researcher in the Department of Physiology and Biomedical Engineering.
A Closed-Loop Approach
In a study published February 6 in Nature Communications, Youssef Ezzyat, PhD, a senior data scientist at the University of Pennsylvania in Philadelphia, and colleagues found that a closed-loop stimulation system may identify periods of poor memory encoding and apply targeted stimulation to the lateral temporal cortex to compensate.
The investigators recruited 25 neurosurgical patients undergoing clinical monitoring for epilepsy to participate in sessions of a delayed free-recall memory task. Subjects completed at least three record-only sessions of free recall with which the researchers trained a system to use intracranial EEG activity during encoding to predict the likelihood of later word recall.
During subsequent sessions, if the system predicted that the probability of recall was less than 0.5, it triggered 500 ms of bipolar stimulation. The researchers found that lateral temporal cortex stimulation increased the relative probability of item recall by 15%.
“By developing patient-specific, personalized, machine-learning models, we could program our stimulator to deliver pulses only when memory was predicted to fail, giving this technology the best chance of restoring memory function,” said Michael Kahana, PhD, Professor of Psychology at the University of Pennsylvania and principal investigator of the Restoring Active Memory program. “This [approach] was important, because we knew from earlier work that stimulating the brain during periods of good function was likely to make memory worse.”
—Jake Remaly
Suggested Reading
Ezzyat Y, Wanda PA, Levy DF, et al. Closed-loop stimulation of temporal cortex rescues functional networks and improves memory. Nat Commun. 2018;9(1):365.
Hampson RE, Song D, Robinson BS, et al. Developing a hippocampal neural prosthetic to facilitate human memory encoding and recall. J Neural Eng. 2018;15(3):036014.
Inman CS, Manns JR, Bijanki KR, et al. Direct electrical stimulation of the amygdala enhances declarative memory in humans. Proc Natl Acad Sci U S A. 2018;115(1):98-103.
Kucewicz MT, Berry BM, Kremen V, et al. Electrical stimulation modulates high γ activity and human memory performance. eNeuro. 2018;5(1).
Kucewicz MT, Berry BM, Miller LR, et al. Evidence for verbal memory enhancement with electrical brain stimulation in the lateral temporal cortex. Brain. 2018;141(4):971-978.
Electrical stimulation in the lateral temporal cortex enhances verbal memory performance, according to two studies in patients with epilepsy.
“While electrical stimulation of the brain is emerging as potential therapy for a wide range of neurologic and psychiatric diseases, little is known about its effect on memory,” said Gregory Worrell, MD, PhD, Professor of Neurology at the Mayo Clinic in Rochester, Minnesota, and an author of the studies. Electrical stimulation may have the potential to treat memory deficits and cognitive dysfunction in brain disorders such as traumatic brain injury and Alzheimer’s disease, the researchers said.
The two studies were part of a multicenter project designed to assess the effects of electrical stimulation on memory-related brain function and were supported by the Defense Advanced Research Projects Agency’s Restoring Active Memory program.
Patients Were Tested During Seizure Monitoring
In the April issue of Brain, Michal T. Kucewicz, PhD, a researcher at the Mayo Clinic, and colleagues described a study of patients with epilepsy who were undergoing evaluation for resective surgery. As part of the evaluations, patients had intracranial subdural and depth electrode arrays implanted in cortical and subcortical brain regions.
After implantation, patients completed delayed free-recall memory tasks in which they learned lists of words for subsequent recall. Twelve words appeared one at a time on a laptop screen for 1.6 seconds each. Participants then solved a series of arithmetic problems. Afterward, participants had 30 seconds to verbally recall as many words as possible from the list in any order. Patients completed this procedure 25 times during each testing session. Twenty of the lists in each session were learned with stimulation (ie, with stimulation applied for two words and then turned off for two words throughout the list), and five lists were learned without stimulation. Participants completed at least two control sessions with no stimulation to reduce potential learning effects.
The investigators focused on 22 patients (nine males) who had electrodes implanted in four brain regions known to support declarative memory: the hippocampus (n = 6), the parahippocampal cortex (n = 7), the prefrontal cortex (n = 6), and the temporal cortex (n = 4). One subject received stimulation in two of the brain regions (ie, the temporal cortex and the parahippocampal cortex).
The number of sessions that patients completed was determined by the length of seizure monitoring (range, two days to 14 days) and patients’ willingness to participate in the study. The subjects were blinded to the stimulation site.
Within-Individual and Between-Group Effects
Stimulation in the lateral temporal cortex enhanced memory performance, whereas stimulation in other brain regions did not. “The positive effect of [lateral cortex] stimulation was reported in individual patients tested across multiple days of stimulation sessions, on the level of the group of patients stimulated in the temporal cortex, and between the four groups stimulated in different brain regions,” the researchers said.
Two of the four patients stimulated in the lateral temporal cortex had significantly improved recall with stimulation, and the other two patients showed a positive trend.
In the subject who received stimulation in two brain regions, stimulation in the dominant lateral temporal neocortex increased the number of remembered words above the normal range, whereas stimulation in the parahippocampal region did not.
Among the participants who received temporal cortex stimulation, memory performance within each session on the stimulated word lists was consistently higher than on the control lists without stimulation.
For the stimulated lists, memory enhancement was observed on the level of the entire list, with no difference in recall between stimulated and nonstimulated words. This finding suggests that the positive effect of stimulation lasted beyond the period of electrical current administration, the researchers said.
The study’s limitations include the small number of participants and their variable clinical characteristics (eg, epilepsy pathologies, medications, and baseline cognition). It is unclear whether electrical stimulation modulates memory processing, attention, perception, or other related processes, the researchers noted. It also is not known whether the positive effect generalizes to other verbal and nonverbal memory functions, or whether stimulation in the nondominant hemisphere would have a different effect.
The data “might provide a hint as to why some patients undergoing surgical removal of this region complain about verbal memory deficits,” Dr. Kucewicz and colleagues said.
“The next step for this project is to determine how to best apply electrical current in terms of the exact location within this area of the brain, timing, and parameters of stimulation,” said study author Brent Berry, MD, PhD, a Mayo Clinic researcher in the Department of Physiology and Biomedical Engineering.
A Closed-Loop Approach
In a study published February 6 in Nature Communications, Youssef Ezzyat, PhD, a senior data scientist at the University of Pennsylvania in Philadelphia, and colleagues found that a closed-loop stimulation system may identify periods of poor memory encoding and apply targeted stimulation to the lateral temporal cortex to compensate.
The investigators recruited 25 neurosurgical patients undergoing clinical monitoring for epilepsy to participate in sessions of a delayed free-recall memory task. Subjects completed at least three record-only sessions of free recall with which the researchers trained a system to use intracranial EEG activity during encoding to predict the likelihood of later word recall.
During subsequent sessions, if the system predicted that the probability of recall was less than 0.5, it triggered 500 ms of bipolar stimulation. The researchers found that lateral temporal cortex stimulation increased the relative probability of item recall by 15%.
“By developing patient-specific, personalized, machine-learning models, we could program our stimulator to deliver pulses only when memory was predicted to fail, giving this technology the best chance of restoring memory function,” said Michael Kahana, PhD, Professor of Psychology at the University of Pennsylvania and principal investigator of the Restoring Active Memory program. “This [approach] was important, because we knew from earlier work that stimulating the brain during periods of good function was likely to make memory worse.”
—Jake Remaly
Suggested Reading
Ezzyat Y, Wanda PA, Levy DF, et al. Closed-loop stimulation of temporal cortex rescues functional networks and improves memory. Nat Commun. 2018;9(1):365.
Hampson RE, Song D, Robinson BS, et al. Developing a hippocampal neural prosthetic to facilitate human memory encoding and recall. J Neural Eng. 2018;15(3):036014.
Inman CS, Manns JR, Bijanki KR, et al. Direct electrical stimulation of the amygdala enhances declarative memory in humans. Proc Natl Acad Sci U S A. 2018;115(1):98-103.
Kucewicz MT, Berry BM, Kremen V, et al. Electrical stimulation modulates high γ activity and human memory performance. eNeuro. 2018;5(1).
Kucewicz MT, Berry BM, Miller LR, et al. Evidence for verbal memory enhancement with electrical brain stimulation in the lateral temporal cortex. Brain. 2018;141(4):971-978.
Hyponatremia After Traumatic Brain Injury
Hyponatremia is a dangerous complication of major head trauma, and timely diagnosis and treatment can be fraught with “confounding factors” and complexity, say clinicians from the University of Newcastle and John Hunter Hospital in Australia. They reported a case of hyponatremia that required some clinical tightrope walking.
The patient, a 20-year-old university student, had fractured his skull in a skateboard fall while intoxicated. He was started on dexamethasone to reduce the risk of worsening cerebral edema. On day 3, he developed hypo-osmolar hyponatremia, which was worse on day 4, despite treatment, including IV fluid therapy, fluid restriction, and oral salt tablets. Although cognitively the patient was deteriorating, he seemed clinically euvolemic. However, the patient was in negative fluid balance, suggesting renal salt wasting (RSW). After a trial of isotonic normal saline, the patient’s serum sodium level fell further. The patient was then treated for suspected syndrome of inappropriate antidiuretic hormone (SIADH) with a hypertonic saline infusion. The rise in sodium was carefully controlled to avoid rapid overcorrection, which can lead to irreversible neurologic symptoms. Finally, the patient’s sodium level and neurologic status improved.
The clinicians say the case demonstrates the complexity of differentiating between the causes of hyponatremia after head injury. Volume status may be an indicator, they say, but current clinical and laboratory markers of volume status are often limited in accuracy. The hallmark of RSW is volume depletion, whereas diagnosis of SIADH depends on a coexisting euvolemic state (as with the patient).
As many as 10% of victims of traumatic brain injury develop hyponatremia, and it is associated with a worse prognosis, even in mild cases, the clinicians note. Making the right diagnosis is critical—the treatment chosen can easily compromise the outcome. Patients with neurosurgical conditions are often treated with considerable volumes of saline-containing fluid, with consequent dynamic changes in blood and extracellular volumes. Moreover, the patients have elevated levels of adrenergic hormones with their own confounding effects.
In the long term, the patient experienced significant neurologic sequelae, including prolonged posttraumatic amnesia. After extensive rehabilitation he was able to return to the university.
Hyponatremia is a dangerous complication of major head trauma, and timely diagnosis and treatment can be fraught with “confounding factors” and complexity, say clinicians from the University of Newcastle and John Hunter Hospital in Australia. They reported a case of hyponatremia that required some clinical tightrope walking.
The patient, a 20-year-old university student, had fractured his skull in a skateboard fall while intoxicated. He was started on dexamethasone to reduce the risk of worsening cerebral edema. On day 3, he developed hypo-osmolar hyponatremia, which was worse on day 4, despite treatment, including IV fluid therapy, fluid restriction, and oral salt tablets. Although cognitively the patient was deteriorating, he seemed clinically euvolemic. However, the patient was in negative fluid balance, suggesting renal salt wasting (RSW). After a trial of isotonic normal saline, the patient’s serum sodium level fell further. The patient was then treated for suspected syndrome of inappropriate antidiuretic hormone (SIADH) with a hypertonic saline infusion. The rise in sodium was carefully controlled to avoid rapid overcorrection, which can lead to irreversible neurologic symptoms. Finally, the patient’s sodium level and neurologic status improved.
The clinicians say the case demonstrates the complexity of differentiating between the causes of hyponatremia after head injury. Volume status may be an indicator, they say, but current clinical and laboratory markers of volume status are often limited in accuracy. The hallmark of RSW is volume depletion, whereas diagnosis of SIADH depends on a coexisting euvolemic state (as with the patient).
As many as 10% of victims of traumatic brain injury develop hyponatremia, and it is associated with a worse prognosis, even in mild cases, the clinicians note. Making the right diagnosis is critical—the treatment chosen can easily compromise the outcome. Patients with neurosurgical conditions are often treated with considerable volumes of saline-containing fluid, with consequent dynamic changes in blood and extracellular volumes. Moreover, the patients have elevated levels of adrenergic hormones with their own confounding effects.
In the long term, the patient experienced significant neurologic sequelae, including prolonged posttraumatic amnesia. After extensive rehabilitation he was able to return to the university.
Hyponatremia is a dangerous complication of major head trauma, and timely diagnosis and treatment can be fraught with “confounding factors” and complexity, say clinicians from the University of Newcastle and John Hunter Hospital in Australia. They reported a case of hyponatremia that required some clinical tightrope walking.
The patient, a 20-year-old university student, had fractured his skull in a skateboard fall while intoxicated. He was started on dexamethasone to reduce the risk of worsening cerebral edema. On day 3, he developed hypo-osmolar hyponatremia, which was worse on day 4, despite treatment, including IV fluid therapy, fluid restriction, and oral salt tablets. Although cognitively the patient was deteriorating, he seemed clinically euvolemic. However, the patient was in negative fluid balance, suggesting renal salt wasting (RSW). After a trial of isotonic normal saline, the patient’s serum sodium level fell further. The patient was then treated for suspected syndrome of inappropriate antidiuretic hormone (SIADH) with a hypertonic saline infusion. The rise in sodium was carefully controlled to avoid rapid overcorrection, which can lead to irreversible neurologic symptoms. Finally, the patient’s sodium level and neurologic status improved.
The clinicians say the case demonstrates the complexity of differentiating between the causes of hyponatremia after head injury. Volume status may be an indicator, they say, but current clinical and laboratory markers of volume status are often limited in accuracy. The hallmark of RSW is volume depletion, whereas diagnosis of SIADH depends on a coexisting euvolemic state (as with the patient).
As many as 10% of victims of traumatic brain injury develop hyponatremia, and it is associated with a worse prognosis, even in mild cases, the clinicians note. Making the right diagnosis is critical—the treatment chosen can easily compromise the outcome. Patients with neurosurgical conditions are often treated with considerable volumes of saline-containing fluid, with consequent dynamic changes in blood and extracellular volumes. Moreover, the patients have elevated levels of adrenergic hormones with their own confounding effects.
In the long term, the patient experienced significant neurologic sequelae, including prolonged posttraumatic amnesia. After extensive rehabilitation he was able to return to the university.
Filling a Gender Gap in Research
Women, the VA wants your brains. It sounds a little disconcerting at first, but the National Center for PTSD and the nonprofit PINK Concussions are encouraging women to donate their brains for research.
In the past, says Dr. Carolyn Clancy, executive in charge of Veterans Health Administration, “the focus on TBI and PTSD brain research has primarily been based on male brains, without any active recruitment for women.” There has been almost no postmortem brain tissue available for study of injury in women. The VA also notes a lack of research on chronic traumatic encephalopathy in women. Only 2 peer-reviewed journal articles, both published in the early 1990s, have focused on women.
Women who are interested can take the “PINK Brain Pledge,” a nonbinding promise to leave their brains to science. They do not have to have a history of TBI or PTSD; brains also are needed for controls.
Women, the VA wants your brains. It sounds a little disconcerting at first, but the National Center for PTSD and the nonprofit PINK Concussions are encouraging women to donate their brains for research.
In the past, says Dr. Carolyn Clancy, executive in charge of Veterans Health Administration, “the focus on TBI and PTSD brain research has primarily been based on male brains, without any active recruitment for women.” There has been almost no postmortem brain tissue available for study of injury in women. The VA also notes a lack of research on chronic traumatic encephalopathy in women. Only 2 peer-reviewed journal articles, both published in the early 1990s, have focused on women.
Women who are interested can take the “PINK Brain Pledge,” a nonbinding promise to leave their brains to science. They do not have to have a history of TBI or PTSD; brains also are needed for controls.
Women, the VA wants your brains. It sounds a little disconcerting at first, but the National Center for PTSD and the nonprofit PINK Concussions are encouraging women to donate their brains for research.
In the past, says Dr. Carolyn Clancy, executive in charge of Veterans Health Administration, “the focus on TBI and PTSD brain research has primarily been based on male brains, without any active recruitment for women.” There has been almost no postmortem brain tissue available for study of injury in women. The VA also notes a lack of research on chronic traumatic encephalopathy in women. Only 2 peer-reviewed journal articles, both published in the early 1990s, have focused on women.
Women who are interested can take the “PINK Brain Pledge,” a nonbinding promise to leave their brains to science. They do not have to have a history of TBI or PTSD; brains also are needed for controls.
Children, adolescents with TBI at risk of secondary ADHD
FROM JAMA PEDIATRICS
Children and adolescents with traumatic brain injury (TBI) might be at increased risk of developing attention-deficit/hyperactivity disorder (ADHD) years after the injury, a prospective cohort study published March 19 shows.
Severe TBI was associated with significantly increased risk of new onset ADHD versus controls in the study, which was based on parent-completed assessments done as late as 6.8 years after the initial injury, according to results presented in JAMA Pediatrics.
Although children with severe TBI were at highest risk, those with less severe TBI had about twice the risk of developing ADHD, compared with control subjects who had no brain injury, the study results suggest.
Taken together, the findings suggest a need for long-term monitoring for attention problems, wrote investigator Megan E. Narad, PhD, of Cincinnati Children’s Hospital Medical Center, and her co-authors.
“Physicians and other clinicians should continue to be vigilant in monitoring attention problems in patients with a history of brain injury, even if it has been a number of years since the injury, the injury was moderate in nature, or the patient experienced a predominantly positive recovery,” Dr. Narad and her colleagues wrote.
The results were based on long-term analysis of 187 children who were hospitalized for TBI or orthopedic injury between the ages of 3 and 7 years. That group included 81 children with TBI and 106 with orthopedic injury.
Parents completed assessments soon after the injury, then again at 6 months, 12 months, 18 months, 3.4 years, and 6.8 years afterward, according to the study.
Over the full follow-up period, 48 children (25.7%) met the investigators’ definition of “secondary ADHD,” or onset of ADHD symptoms after an injury. They found that compared with orthopedic injury, the severe TBI was associated with new ADHD (hazard ratio, 3.62; 95% confidence interval, 1.59-8.26), the investigators reported.
In patients with mild or moderate TBI, associations with new onset ADHD did not meet the statistical significance threshol. However, compared with the orthopedic injury group, the risk for ADHD in TBI severity subgroups were up to 4 times higher.
This is not the first study showing an elevated risk of ADHD in TBI patients, but .
“Although most children with severe TBI who developed secondary ADHD did so within the first 18 months after injury, a portion of those with complicated mild and moderate TBI demonstrated new onset of secondary ADHD at the final two assessments, highlighting the importance of continued monitoring even years after TBI,” Dr. Narad and her colleagues wrote.
The study was funded by several sources, including the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the state of Ohio’s Emergency Medical Services.
Dr. Narad reported no relevant disclosures. Other study authors reported disclosures related to Akili Interactive Labs, Multi-Health Systems, Optimal Medicine, and IXICO.
SOURCE: Narad ME et al. JAMA Pediatr. 2018 Mar 19. doi: 10.1001/jamapediatrics.2017.5746.
FROM JAMA PEDIATRICS
Children and adolescents with traumatic brain injury (TBI) might be at increased risk of developing attention-deficit/hyperactivity disorder (ADHD) years after the injury, a prospective cohort study published March 19 shows.
Severe TBI was associated with significantly increased risk of new onset ADHD versus controls in the study, which was based on parent-completed assessments done as late as 6.8 years after the initial injury, according to results presented in JAMA Pediatrics.
Although children with severe TBI were at highest risk, those with less severe TBI had about twice the risk of developing ADHD, compared with control subjects who had no brain injury, the study results suggest.
Taken together, the findings suggest a need for long-term monitoring for attention problems, wrote investigator Megan E. Narad, PhD, of Cincinnati Children’s Hospital Medical Center, and her co-authors.
“Physicians and other clinicians should continue to be vigilant in monitoring attention problems in patients with a history of brain injury, even if it has been a number of years since the injury, the injury was moderate in nature, or the patient experienced a predominantly positive recovery,” Dr. Narad and her colleagues wrote.
The results were based on long-term analysis of 187 children who were hospitalized for TBI or orthopedic injury between the ages of 3 and 7 years. That group included 81 children with TBI and 106 with orthopedic injury.
Parents completed assessments soon after the injury, then again at 6 months, 12 months, 18 months, 3.4 years, and 6.8 years afterward, according to the study.
Over the full follow-up period, 48 children (25.7%) met the investigators’ definition of “secondary ADHD,” or onset of ADHD symptoms after an injury. They found that compared with orthopedic injury, the severe TBI was associated with new ADHD (hazard ratio, 3.62; 95% confidence interval, 1.59-8.26), the investigators reported.
In patients with mild or moderate TBI, associations with new onset ADHD did not meet the statistical significance threshol. However, compared with the orthopedic injury group, the risk for ADHD in TBI severity subgroups were up to 4 times higher.
This is not the first study showing an elevated risk of ADHD in TBI patients, but .
“Although most children with severe TBI who developed secondary ADHD did so within the first 18 months after injury, a portion of those with complicated mild and moderate TBI demonstrated new onset of secondary ADHD at the final two assessments, highlighting the importance of continued monitoring even years after TBI,” Dr. Narad and her colleagues wrote.
The study was funded by several sources, including the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the state of Ohio’s Emergency Medical Services.
Dr. Narad reported no relevant disclosures. Other study authors reported disclosures related to Akili Interactive Labs, Multi-Health Systems, Optimal Medicine, and IXICO.
SOURCE: Narad ME et al. JAMA Pediatr. 2018 Mar 19. doi: 10.1001/jamapediatrics.2017.5746.
FROM JAMA PEDIATRICS
Children and adolescents with traumatic brain injury (TBI) might be at increased risk of developing attention-deficit/hyperactivity disorder (ADHD) years after the injury, a prospective cohort study published March 19 shows.
Severe TBI was associated with significantly increased risk of new onset ADHD versus controls in the study, which was based on parent-completed assessments done as late as 6.8 years after the initial injury, according to results presented in JAMA Pediatrics.
Although children with severe TBI were at highest risk, those with less severe TBI had about twice the risk of developing ADHD, compared with control subjects who had no brain injury, the study results suggest.
Taken together, the findings suggest a need for long-term monitoring for attention problems, wrote investigator Megan E. Narad, PhD, of Cincinnati Children’s Hospital Medical Center, and her co-authors.
“Physicians and other clinicians should continue to be vigilant in monitoring attention problems in patients with a history of brain injury, even if it has been a number of years since the injury, the injury was moderate in nature, or the patient experienced a predominantly positive recovery,” Dr. Narad and her colleagues wrote.
The results were based on long-term analysis of 187 children who were hospitalized for TBI or orthopedic injury between the ages of 3 and 7 years. That group included 81 children with TBI and 106 with orthopedic injury.
Parents completed assessments soon after the injury, then again at 6 months, 12 months, 18 months, 3.4 years, and 6.8 years afterward, according to the study.
Over the full follow-up period, 48 children (25.7%) met the investigators’ definition of “secondary ADHD,” or onset of ADHD symptoms after an injury. They found that compared with orthopedic injury, the severe TBI was associated with new ADHD (hazard ratio, 3.62; 95% confidence interval, 1.59-8.26), the investigators reported.
In patients with mild or moderate TBI, associations with new onset ADHD did not meet the statistical significance threshol. However, compared with the orthopedic injury group, the risk for ADHD in TBI severity subgroups were up to 4 times higher.
This is not the first study showing an elevated risk of ADHD in TBI patients, but .
“Although most children with severe TBI who developed secondary ADHD did so within the first 18 months after injury, a portion of those with complicated mild and moderate TBI demonstrated new onset of secondary ADHD at the final two assessments, highlighting the importance of continued monitoring even years after TBI,” Dr. Narad and her colleagues wrote.
The study was funded by several sources, including the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the state of Ohio’s Emergency Medical Services.
Dr. Narad reported no relevant disclosures. Other study authors reported disclosures related to Akili Interactive Labs, Multi-Health Systems, Optimal Medicine, and IXICO.
SOURCE: Narad ME et al. JAMA Pediatr. 2018 Mar 19. doi: 10.1001/jamapediatrics.2017.5746.
Key clinical point: Children and adolescents with traumatic brain injury (TBI) should continue to be monitored for possible attention problems many years after the injury.
Major finding: In assessments taken up to 6.8 years after injury, severe TBI was associated with secondary ADHD, compared with a control group (hazard ratio, 3.62; 95% confidence interval, 1.59-8.26).
Study details: Analysis of a prospective concurrent cohort study including 187 children aged 3 to 7 years who were hospitalized for TBI or orthopedic injury.
Disclosures: The study was funded by several sources, including the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the state of Ohio’s Emergency Medical Services. The authors reported conflict of interest disclosures related to Akili Interactive Labs, Multi-Health Systems, Optimal Medicine, and IXICO.
Source: Narad ME et al. JAMA Pediatr. 2018 Mar 19. doi:10.1001/jamapediatrics.2017.5746.
Stroke Patients May Have a Wider Window of Treatment Opportunity
Thrombectomy is currently approved for use up to 6 hours after symptom onset; the researchers from the Endovascular Therapy Following Imaging Evaluation for the Ischemic Stroke (DEFUSE 3) trial discovered that even 16 hours after symptom onset, the procedure could improve outcomes compared with those of standard medical therapy.
Using automated software to analyze perfusion magnetic resonance imaging or computer tomography scans, the researchers identified patients thought to have salvageable tissue. The patients were randomly assigned to receive endovascular thrombectomy plus standard medical therapy or medical therapy alone.
In the thrombectomy group, 45% of patients achieved functional independence compared with 17% of the control group. Thrombectomy also was associated with improved survival: 14% of the treated group died within 90 days of the study compared with 26% of the control group.
The DEFUSE 3 trial is a large study supported by StrokeNet, a network of hospitals providing research infrastructure for multisite clinical trials, in this case, at 38 centers. The study was ended early because of “overwhelming” evidence of benefit from the clot removal procedure.
“These striking results will have an immediate impact and save people from lifelong disability or death,” said Walter Korshetz, MD, director of the National Institute of Neurological Disorders and Stroke. “I really cannot overstate the size of this effect.” He adds that 1 of 3 stroke patients with at-risk brain tissue improves, and some may walk out of the hospital “saved from what would otherwise have been a devastating brain injury.”
Thrombectomy is currently approved for use up to 6 hours after symptom onset; the researchers from the Endovascular Therapy Following Imaging Evaluation for the Ischemic Stroke (DEFUSE 3) trial discovered that even 16 hours after symptom onset, the procedure could improve outcomes compared with those of standard medical therapy.
Using automated software to analyze perfusion magnetic resonance imaging or computer tomography scans, the researchers identified patients thought to have salvageable tissue. The patients were randomly assigned to receive endovascular thrombectomy plus standard medical therapy or medical therapy alone.
In the thrombectomy group, 45% of patients achieved functional independence compared with 17% of the control group. Thrombectomy also was associated with improved survival: 14% of the treated group died within 90 days of the study compared with 26% of the control group.
The DEFUSE 3 trial is a large study supported by StrokeNet, a network of hospitals providing research infrastructure for multisite clinical trials, in this case, at 38 centers. The study was ended early because of “overwhelming” evidence of benefit from the clot removal procedure.
“These striking results will have an immediate impact and save people from lifelong disability or death,” said Walter Korshetz, MD, director of the National Institute of Neurological Disorders and Stroke. “I really cannot overstate the size of this effect.” He adds that 1 of 3 stroke patients with at-risk brain tissue improves, and some may walk out of the hospital “saved from what would otherwise have been a devastating brain injury.”
Thrombectomy is currently approved for use up to 6 hours after symptom onset; the researchers from the Endovascular Therapy Following Imaging Evaluation for the Ischemic Stroke (DEFUSE 3) trial discovered that even 16 hours after symptom onset, the procedure could improve outcomes compared with those of standard medical therapy.
Using automated software to analyze perfusion magnetic resonance imaging or computer tomography scans, the researchers identified patients thought to have salvageable tissue. The patients were randomly assigned to receive endovascular thrombectomy plus standard medical therapy or medical therapy alone.
In the thrombectomy group, 45% of patients achieved functional independence compared with 17% of the control group. Thrombectomy also was associated with improved survival: 14% of the treated group died within 90 days of the study compared with 26% of the control group.
The DEFUSE 3 trial is a large study supported by StrokeNet, a network of hospitals providing research infrastructure for multisite clinical trials, in this case, at 38 centers. The study was ended early because of “overwhelming” evidence of benefit from the clot removal procedure.
“These striking results will have an immediate impact and save people from lifelong disability or death,” said Walter Korshetz, MD, director of the National Institute of Neurological Disorders and Stroke. “I really cannot overstate the size of this effect.” He adds that 1 of 3 stroke patients with at-risk brain tissue improves, and some may walk out of the hospital “saved from what would otherwise have been a devastating brain injury.”
Windows to the Brain
“We were kind of astounded by this—it’s a very unrecognized phenomenon,” said Richard Leigh, MD, assistant clinical investigator at the National Institute of Neurological Disorders and Stroke (NINDS). Dr. Leigh and his co-researchers had discovered that gadolinium, used in brain scans for stroke patients, sometimes leaks into eyes—literally highlighting abnormalities. The finding could lead to more accurate stroke treatment.
The researchers performed MRI scans on 167 stroke patients on admission to the hospital without administering gadolinium and compared those scans to scans taken using gadolinium 2 hours and 24 hours later.
They found that the gadolinium made some eyes glow brightly, marking the location of brain damage. It appeared that the stroke could compromise the blood-ocular barrier. “It looks like the stroke is influencing the eye, and so the eye is reflective of what is going on in the brain,” said Dr. Leigh.
In about three-fourths of patients, gadolinium leaked into the eyes on 1 of the scans: 66% in the 2-hour scan (typically leaking in the aqueous chamber, in the front of the eye) and 75% in the 24-hour scan (typically in in the vitreous chamber, in the back of the eye).
Older patients, those with hypertension and those with brighter spots on their brain scans (associated with brain aging) were more likely to show gadolinium in the vitreous chamber at 24 hours. In a minority of patients, both eye chambers showed gadolinium at 2 hours. In those patients, stroke tended to affect a larger portion of the brain and cause more damage to the blood-brain barrier than did strokes in patients with a slower pattern of gadolinium leakage or no leakage. The researchers observed the phenomenon in both untreated patients and in those who received tPA.
The findings raise the possibility that clinicians could administer a substance to patients that would collect in the eye, like gadolinium, and quickly yield information about the stroke without the need for an MRI, the researchers say. “It’s much easier for us to look inside somebody’s eye than to look into somebody’s brain,” Dr. Leigh said. “So if the eye truly is a window to the brain, we can use one to learn about the other.”
“We were kind of astounded by this—it’s a very unrecognized phenomenon,” said Richard Leigh, MD, assistant clinical investigator at the National Institute of Neurological Disorders and Stroke (NINDS). Dr. Leigh and his co-researchers had discovered that gadolinium, used in brain scans for stroke patients, sometimes leaks into eyes—literally highlighting abnormalities. The finding could lead to more accurate stroke treatment.
The researchers performed MRI scans on 167 stroke patients on admission to the hospital without administering gadolinium and compared those scans to scans taken using gadolinium 2 hours and 24 hours later.
They found that the gadolinium made some eyes glow brightly, marking the location of brain damage. It appeared that the stroke could compromise the blood-ocular barrier. “It looks like the stroke is influencing the eye, and so the eye is reflective of what is going on in the brain,” said Dr. Leigh.
In about three-fourths of patients, gadolinium leaked into the eyes on 1 of the scans: 66% in the 2-hour scan (typically leaking in the aqueous chamber, in the front of the eye) and 75% in the 24-hour scan (typically in in the vitreous chamber, in the back of the eye).
Older patients, those with hypertension and those with brighter spots on their brain scans (associated with brain aging) were more likely to show gadolinium in the vitreous chamber at 24 hours. In a minority of patients, both eye chambers showed gadolinium at 2 hours. In those patients, stroke tended to affect a larger portion of the brain and cause more damage to the blood-brain barrier than did strokes in patients with a slower pattern of gadolinium leakage or no leakage. The researchers observed the phenomenon in both untreated patients and in those who received tPA.
The findings raise the possibility that clinicians could administer a substance to patients that would collect in the eye, like gadolinium, and quickly yield information about the stroke without the need for an MRI, the researchers say. “It’s much easier for us to look inside somebody’s eye than to look into somebody’s brain,” Dr. Leigh said. “So if the eye truly is a window to the brain, we can use one to learn about the other.”
“We were kind of astounded by this—it’s a very unrecognized phenomenon,” said Richard Leigh, MD, assistant clinical investigator at the National Institute of Neurological Disorders and Stroke (NINDS). Dr. Leigh and his co-researchers had discovered that gadolinium, used in brain scans for stroke patients, sometimes leaks into eyes—literally highlighting abnormalities. The finding could lead to more accurate stroke treatment.
The researchers performed MRI scans on 167 stroke patients on admission to the hospital without administering gadolinium and compared those scans to scans taken using gadolinium 2 hours and 24 hours later.
They found that the gadolinium made some eyes glow brightly, marking the location of brain damage. It appeared that the stroke could compromise the blood-ocular barrier. “It looks like the stroke is influencing the eye, and so the eye is reflective of what is going on in the brain,” said Dr. Leigh.
In about three-fourths of patients, gadolinium leaked into the eyes on 1 of the scans: 66% in the 2-hour scan (typically leaking in the aqueous chamber, in the front of the eye) and 75% in the 24-hour scan (typically in in the vitreous chamber, in the back of the eye).
Older patients, those with hypertension and those with brighter spots on their brain scans (associated with brain aging) were more likely to show gadolinium in the vitreous chamber at 24 hours. In a minority of patients, both eye chambers showed gadolinium at 2 hours. In those patients, stroke tended to affect a larger portion of the brain and cause more damage to the blood-brain barrier than did strokes in patients with a slower pattern of gadolinium leakage or no leakage. The researchers observed the phenomenon in both untreated patients and in those who received tPA.
The findings raise the possibility that clinicians could administer a substance to patients that would collect in the eye, like gadolinium, and quickly yield information about the stroke without the need for an MRI, the researchers say. “It’s much easier for us to look inside somebody’s eye than to look into somebody’s brain,” Dr. Leigh said. “So if the eye truly is a window to the brain, we can use one to learn about the other.”
Conference News Roundup—Association of Academic Physiatrists
Electrical Stimulation Device Improves Motor Function
A person with a spinal cord injury can improve his or her ability to grip and move household objects by using an electrical stimulation device controlled by his or her thoughts, according to researchers. The study suggests that this new technology could one day enhance quality of life among people with disabilities and allow them to live more independently.
People with tetraplegia lose upper-limb strength and dexterity, which has a severe impact on their independence and quality of life. New technology that connects a person’s brain to an implanted functional electrical stimulation orthotics device on the hands could restore manual dexterity and grip strength, thus allowing him or her to perform simple daily tasks like holding a toothbrush without help.
“Individuals with cervical spinal cord injury identify recovery of the use of their hands as the single most impactful way that neurotechnology could change their lives,” said Marcie Bockbrader, MD, PhD, Assistant Professor of Physical Medicine and Rehabilitation at the Ohio State University Wexner Medical Center in Columbus. “Giving a person back [his or her] hands reduces dependence on others. It makes it possible to do the little things—like cutting food or opening a door—that are so essential to being able to take care of oneself.”
To test how well this thought-controlled brain–computer interface system works in real life to improve hand strength and dexterity, Dr. Bockbrader and her research team surgically implanted one of these devices into the hand of a 26-year-old man with C5-level, nonspastic tetraplegia following a spinal cord injury. He practiced using the device three times per week for four hours each session for more than 1,000 days. The research team administered standardized tests of upper-limb motor ability and functional participation to see how well the system improved his grip strength, quickness, and other basic skills.
Using this device improved the man’s upper-limb motor ability dramatically, according to several standardized tests. He improved his ability to grip and manipulate basic objects, and showed that he could perform ordinary tasks with his hands at the speed and dexterity levels of healthy individuals. He could move objects of different sizes and weights. With practice, he improved his ability to manipulate smaller household objects like a toothbrush or hairbrush. He also demonstrated that he could imagine different hand positions to proportionally adjust and control different hand movements.
“Our study demonstrated that patients with tetraplegia might be able to restore some of their skilled hand function with an implanted device that allows them to control movements with their own thoughts,” said Dr. Bockbrader. “Although this technology must be refined and tested before it can go from the laboratory to the public, it may one day offer people with disabilities a way to live and work more independently, and enable them to perform daily tasks.”
Concussion Recovery Varies Among Children
Not all children follow the same path to concussion recovery, nor do they have the same predictors for returning to normal activity, investigators reported. Their study also suggests that younger children should be considered separately from high-school students.
“Concussions are common among children, yet the literature is limited with regard to understanding trajectory of recovery after concussion, particularly in children with non-sports-related injuries and for younger children,” said Kaitlyn Chin, a second-year medical student at University of New England College of Osteopathic Medicine in Biddeford, Maine. “We were particularly interested in understanding how activity levels during recovery from concussion influence time to full recovery, to be able to identify modifiable factors to help guide concussion care. Previous studies have noted differences in the amount of time it takes children to recover from a concussion, and our team recently initiated a study to see if we can identify predictors associated with the amount of time between injury and when a child is medically cleared to return to activities which place the child at risk for reinjury.”
Ms. Chin’s team at Kennedy Krieger Institute in Baltimore reviewed the medical records of 178 children who were treated for concussions at an academically affiliated, rehabilitation-based clinic. The children had been medically cleared to return to play between September 2015 and February 2017. The children included in the study ranged in age from 6 to 17. A slight majority was younger than 14. Each child’s first visit to the clinic was within 60 days of his or her concussion.
The researchers reviewed each child’s record, noting when they had been approved to return to play. Then they looked at several other factors for each child, including sex, cause of the concussion (ie, sports or non-sports-related), number of symptoms, school attendance, and exercise status at the initial visit to the clinic. Finally, they considered these factors when the children were placed into two categories—children under 14 and children over 14—to examine potential differences related to age.
Ms. Chin’s team found that the number of symptoms affected how quickly all children were cleared to return to play. Fewer symptoms were associated with a faster return to play. For older children, male sex and higher level of exercise during recovery were associated with a faster return to play. For younger children, higher levels of exercise and school participation (eg, attending class and completing homework and tests) were associated with faster return to play.
Overall, this study shows that elementary and middle-school-aged children should be considered separately from high-school-aged students when considering risk factors for prolonged recovery from a concussion. Furthermore, Ms. Chin’s team found that school participation and exercise were not harmful and did not prolong recovery.
“Our study adds to the literature supporting that return to cognitive and safe physical activities while a child is still recovering from concussion does not prolong time to recovery,” said Ms. Chin. “Every child is different, and recovery is different for each concussion. [Therefore], a concussion recovery plan should be tailored for each child, and parents should seek help from the child’s pediatrician or other medical professionals for guiding care after a concussion.”
Medicine May Not Affect Concussion Recovery
Medications commonly prescribed to reduce symptoms of concussion may not affect recovery, said investigators. Sports medicine physicians commonly treat patients with concussion, so researchers in Utah investigated how some widely prescribed treatments might affect patients’ recovery.
“We really do not have much other than rest and gentle exercise to combat symptoms of concussion,” said Venessa Lee, MD, a physical medicine and rehabilitation resident at University of Utah Health in Salt Lake City. “Medications are commonly prescribed to help with symptoms, but there is little evidence that they help more than just time and rest.”
Although FDA has not approved any medication to treat concussion, physicians may prescribe medications like gabapentin or tricyclic antidepressants (TCAs) to help reduce symptoms during recovery. To examine whether these drugs benefit patients, Dr. Lee and her research team looked at 277 patients who had been diagnosed with concussion at a local academic sports medicine practice. At each of their visits to the clinic during recovery, patients reported their postconcussion symptoms. The research team used a score sheet to measure their symptoms, and they tracked scores of patients who had more than one visit to the clinic for as long as one year.
Patients were separated into three groups for the study: those not prescribed any medication, those prescribed gabapentin, and those prescribed one of two TCAs, amitriptyline or nortriptyline. Based on self-reported information, investigators gave each patient a score for two factors of postconcussion recovery: headaches and a combination of 22 symptoms, including headaches. Each score was on a scale of 0 to 6.
After they adjusted scores for gender and age, Dr. Lee’s team found that headache and combined symptoms scores decreased significantly within days after the first clinic visit for all three groups of patients—those who had taken no medications, those who had been prescribed gabapentin, and those who had been prescribed a TCA. Patients who had been prescribed any of the medications had significantly higher scores for headaches and overall postconcussion symptoms to begin with, but no one type of medication had any better or worse effect over the duration of the study.
“Patients’ symptoms improve with time after a concussion,” said Dr. Lee. “When we looked at [patients who received] gabapentin and TCAs, their symptoms improved over time as well, but similar to those that did not receive a medication.”
Based on this study, neither gabapentin nor TCAs appear to provide any additional benefit for postconcussion recovery. With this information, patients may be able to avoid taking unnecessary medications as they recover from concussions. Patients should speak with a physician about their symptoms after a concussion, said Dr. Lee.
“Though the two medications we studied did not show a profound improvement in our analysis, this was a retrospective study … which has many drawbacks and limitations. We need to do more research to really find the best method for improving postconcussive symptoms.”
Ballet Helps Children with Musculoskeletal and Neurologic Conditions
Adaptive ballet classes provide functional improvement and social interactions for children with musculoskeletal and neurologic conditions, according to researchers. This type of arts-based adaptive therapy is a promising expansion to successful adaptive sports therapies, said the investigators.
“While great strides have been made in adaptive sports, there are still relatively few opportunities in the arts for people with disabilities,” said Sarah Stauder, MD, a physician at the Medical College of Wisconsin in Milwaukee. “Because of this [scarcity], we wanted to evaluate the effect of adaptive ballet on the physical, emotional, social, and academic function of children with physical impairments. The program is a collaboration between a children’s hospital and a metropolitan ballet company that brings together professional dancers, pediatric doctors, physical and occupational therapists, and children with physical disabilities for a series of dance classes.”
The goal of the study was to see whether a weekly, 45-mintute ballet class with 15 minutes of ballet education over five consecutive weeks would improve the children’s balance, physical functions, social skills, and overall quality of life. Eighteen children (17 girls) from ages 5 to 14, took part in the class. Assessments of each child were performed before and after the series of classes using the Pediatric Quality of Life Inventory, the PEDI-CAT survey, and the Pediatric Balance Scale. Finally, a questionnaire was used to assess each child’s success in achieving individual goals set for the class.
At the end of the five weeks, 94% of participants reached their individual goals for the ballet program. PEDI-CAT scores improved after completion of the program, and the program was most beneficial to participants who had lower functioning and quality of life at the beginning of the program. Finally, the researchers noticed an average improvement in balance among the participants.
“Adaptive programs like the one studied here give children the opportunity to participate in activities they otherwise would have no way to do,” said Dr. Stauder. “More specifically, these dance classes instilled a sense of pride and confidence in the children while improving their physical functioning and quality of life. Our study should open the door to more arts-based therapy for children. It is an effective and enjoyable way for patients to get the therapy they need. When kids are active in an activity that interests them, they naturally make greater strides, and we were able to see this in their day-to-day function.”
Genetic Risk Score Predicts TBI Outcomes
A genetic risk score could help predict a patient’s quality of life after a traumatic brain injury (TBI), said researchers. One day, physicians could have a simple method to forecast a patient’s recovery and personalize therapy to maximize quality of life.
“Gene pathways can influence all of our biologic functions and risk for many health outcomes,” said Mark Linsenmeyer, MD, a resident physician at the University of Pittsburgh Medical Center. “Each person has a unique inherited genetic code. By studying one gene pathway in a large group of people with the same disease or health problem, we hope to unlock clues to why some people have different outcomes than others. This knowledge may be used to help physicians make the best treatment choice for each person.”
Dr. Linsenmeyer and colleagues set out to investigate how genes that affect the brain’s dopamine pathways could predict recovery in people with moderate-to-severe TBI. The team recruited 94 adults with TBI from a level-1 trauma center. They focused on the following five genes in the dopamine pathways: COMT rs4680, VMAT2 rs363226, DRD2 rs6279, ANKK1 Taq1a, and MAOA VNTR. They defined which risk genotypes were associated with lower average scores on surveys filled out by patients with TBI to describe their overall quality of life at six and 12 months after their injuries.
The researchers analyzed how individual variants of each of these five genes could affect patients’ quality of life, and then generated a weighted gene risk score as a measure to reflect cumulative risk represented by all genotypes included in the score. Based on available literature about dopamine pathway genetics, they predicted that their gene risk score calculation tool should be specific to a patient’s sex.
Before they calculated gene risk scores, the research team noticed that only COMT could significantly predict quality of life for a subset of patients six months after their injuries. After generating sex-specific gene risk scores, they found that variants of all five genes on the dopamine pathway could meaningfully contribute to a gene risk score that was highly predictive of quality of life after six months for patients of both sexes with TBI, and also predictive of quality of life after one year for women.
Electrical Stimulation Device Improves Motor Function
A person with a spinal cord injury can improve his or her ability to grip and move household objects by using an electrical stimulation device controlled by his or her thoughts, according to researchers. The study suggests that this new technology could one day enhance quality of life among people with disabilities and allow them to live more independently.
People with tetraplegia lose upper-limb strength and dexterity, which has a severe impact on their independence and quality of life. New technology that connects a person’s brain to an implanted functional electrical stimulation orthotics device on the hands could restore manual dexterity and grip strength, thus allowing him or her to perform simple daily tasks like holding a toothbrush without help.
“Individuals with cervical spinal cord injury identify recovery of the use of their hands as the single most impactful way that neurotechnology could change their lives,” said Marcie Bockbrader, MD, PhD, Assistant Professor of Physical Medicine and Rehabilitation at the Ohio State University Wexner Medical Center in Columbus. “Giving a person back [his or her] hands reduces dependence on others. It makes it possible to do the little things—like cutting food or opening a door—that are so essential to being able to take care of oneself.”
To test how well this thought-controlled brain–computer interface system works in real life to improve hand strength and dexterity, Dr. Bockbrader and her research team surgically implanted one of these devices into the hand of a 26-year-old man with C5-level, nonspastic tetraplegia following a spinal cord injury. He practiced using the device three times per week for four hours each session for more than 1,000 days. The research team administered standardized tests of upper-limb motor ability and functional participation to see how well the system improved his grip strength, quickness, and other basic skills.
Using this device improved the man’s upper-limb motor ability dramatically, according to several standardized tests. He improved his ability to grip and manipulate basic objects, and showed that he could perform ordinary tasks with his hands at the speed and dexterity levels of healthy individuals. He could move objects of different sizes and weights. With practice, he improved his ability to manipulate smaller household objects like a toothbrush or hairbrush. He also demonstrated that he could imagine different hand positions to proportionally adjust and control different hand movements.
“Our study demonstrated that patients with tetraplegia might be able to restore some of their skilled hand function with an implanted device that allows them to control movements with their own thoughts,” said Dr. Bockbrader. “Although this technology must be refined and tested before it can go from the laboratory to the public, it may one day offer people with disabilities a way to live and work more independently, and enable them to perform daily tasks.”
Concussion Recovery Varies Among Children
Not all children follow the same path to concussion recovery, nor do they have the same predictors for returning to normal activity, investigators reported. Their study also suggests that younger children should be considered separately from high-school students.
“Concussions are common among children, yet the literature is limited with regard to understanding trajectory of recovery after concussion, particularly in children with non-sports-related injuries and for younger children,” said Kaitlyn Chin, a second-year medical student at University of New England College of Osteopathic Medicine in Biddeford, Maine. “We were particularly interested in understanding how activity levels during recovery from concussion influence time to full recovery, to be able to identify modifiable factors to help guide concussion care. Previous studies have noted differences in the amount of time it takes children to recover from a concussion, and our team recently initiated a study to see if we can identify predictors associated with the amount of time between injury and when a child is medically cleared to return to activities which place the child at risk for reinjury.”
Ms. Chin’s team at Kennedy Krieger Institute in Baltimore reviewed the medical records of 178 children who were treated for concussions at an academically affiliated, rehabilitation-based clinic. The children had been medically cleared to return to play between September 2015 and February 2017. The children included in the study ranged in age from 6 to 17. A slight majority was younger than 14. Each child’s first visit to the clinic was within 60 days of his or her concussion.
The researchers reviewed each child’s record, noting when they had been approved to return to play. Then they looked at several other factors for each child, including sex, cause of the concussion (ie, sports or non-sports-related), number of symptoms, school attendance, and exercise status at the initial visit to the clinic. Finally, they considered these factors when the children were placed into two categories—children under 14 and children over 14—to examine potential differences related to age.
Ms. Chin’s team found that the number of symptoms affected how quickly all children were cleared to return to play. Fewer symptoms were associated with a faster return to play. For older children, male sex and higher level of exercise during recovery were associated with a faster return to play. For younger children, higher levels of exercise and school participation (eg, attending class and completing homework and tests) were associated with faster return to play.
Overall, this study shows that elementary and middle-school-aged children should be considered separately from high-school-aged students when considering risk factors for prolonged recovery from a concussion. Furthermore, Ms. Chin’s team found that school participation and exercise were not harmful and did not prolong recovery.
“Our study adds to the literature supporting that return to cognitive and safe physical activities while a child is still recovering from concussion does not prolong time to recovery,” said Ms. Chin. “Every child is different, and recovery is different for each concussion. [Therefore], a concussion recovery plan should be tailored for each child, and parents should seek help from the child’s pediatrician or other medical professionals for guiding care after a concussion.”
Medicine May Not Affect Concussion Recovery
Medications commonly prescribed to reduce symptoms of concussion may not affect recovery, said investigators. Sports medicine physicians commonly treat patients with concussion, so researchers in Utah investigated how some widely prescribed treatments might affect patients’ recovery.
“We really do not have much other than rest and gentle exercise to combat symptoms of concussion,” said Venessa Lee, MD, a physical medicine and rehabilitation resident at University of Utah Health in Salt Lake City. “Medications are commonly prescribed to help with symptoms, but there is little evidence that they help more than just time and rest.”
Although FDA has not approved any medication to treat concussion, physicians may prescribe medications like gabapentin or tricyclic antidepressants (TCAs) to help reduce symptoms during recovery. To examine whether these drugs benefit patients, Dr. Lee and her research team looked at 277 patients who had been diagnosed with concussion at a local academic sports medicine practice. At each of their visits to the clinic during recovery, patients reported their postconcussion symptoms. The research team used a score sheet to measure their symptoms, and they tracked scores of patients who had more than one visit to the clinic for as long as one year.
Patients were separated into three groups for the study: those not prescribed any medication, those prescribed gabapentin, and those prescribed one of two TCAs, amitriptyline or nortriptyline. Based on self-reported information, investigators gave each patient a score for two factors of postconcussion recovery: headaches and a combination of 22 symptoms, including headaches. Each score was on a scale of 0 to 6.
After they adjusted scores for gender and age, Dr. Lee’s team found that headache and combined symptoms scores decreased significantly within days after the first clinic visit for all three groups of patients—those who had taken no medications, those who had been prescribed gabapentin, and those who had been prescribed a TCA. Patients who had been prescribed any of the medications had significantly higher scores for headaches and overall postconcussion symptoms to begin with, but no one type of medication had any better or worse effect over the duration of the study.
“Patients’ symptoms improve with time after a concussion,” said Dr. Lee. “When we looked at [patients who received] gabapentin and TCAs, their symptoms improved over time as well, but similar to those that did not receive a medication.”
Based on this study, neither gabapentin nor TCAs appear to provide any additional benefit for postconcussion recovery. With this information, patients may be able to avoid taking unnecessary medications as they recover from concussions. Patients should speak with a physician about their symptoms after a concussion, said Dr. Lee.
“Though the two medications we studied did not show a profound improvement in our analysis, this was a retrospective study … which has many drawbacks and limitations. We need to do more research to really find the best method for improving postconcussive symptoms.”
Ballet Helps Children with Musculoskeletal and Neurologic Conditions
Adaptive ballet classes provide functional improvement and social interactions for children with musculoskeletal and neurologic conditions, according to researchers. This type of arts-based adaptive therapy is a promising expansion to successful adaptive sports therapies, said the investigators.
“While great strides have been made in adaptive sports, there are still relatively few opportunities in the arts for people with disabilities,” said Sarah Stauder, MD, a physician at the Medical College of Wisconsin in Milwaukee. “Because of this [scarcity], we wanted to evaluate the effect of adaptive ballet on the physical, emotional, social, and academic function of children with physical impairments. The program is a collaboration between a children’s hospital and a metropolitan ballet company that brings together professional dancers, pediatric doctors, physical and occupational therapists, and children with physical disabilities for a series of dance classes.”
The goal of the study was to see whether a weekly, 45-mintute ballet class with 15 minutes of ballet education over five consecutive weeks would improve the children’s balance, physical functions, social skills, and overall quality of life. Eighteen children (17 girls) from ages 5 to 14, took part in the class. Assessments of each child were performed before and after the series of classes using the Pediatric Quality of Life Inventory, the PEDI-CAT survey, and the Pediatric Balance Scale. Finally, a questionnaire was used to assess each child’s success in achieving individual goals set for the class.
At the end of the five weeks, 94% of participants reached their individual goals for the ballet program. PEDI-CAT scores improved after completion of the program, and the program was most beneficial to participants who had lower functioning and quality of life at the beginning of the program. Finally, the researchers noticed an average improvement in balance among the participants.
“Adaptive programs like the one studied here give children the opportunity to participate in activities they otherwise would have no way to do,” said Dr. Stauder. “More specifically, these dance classes instilled a sense of pride and confidence in the children while improving their physical functioning and quality of life. Our study should open the door to more arts-based therapy for children. It is an effective and enjoyable way for patients to get the therapy they need. When kids are active in an activity that interests them, they naturally make greater strides, and we were able to see this in their day-to-day function.”
Genetic Risk Score Predicts TBI Outcomes
A genetic risk score could help predict a patient’s quality of life after a traumatic brain injury (TBI), said researchers. One day, physicians could have a simple method to forecast a patient’s recovery and personalize therapy to maximize quality of life.
“Gene pathways can influence all of our biologic functions and risk for many health outcomes,” said Mark Linsenmeyer, MD, a resident physician at the University of Pittsburgh Medical Center. “Each person has a unique inherited genetic code. By studying one gene pathway in a large group of people with the same disease or health problem, we hope to unlock clues to why some people have different outcomes than others. This knowledge may be used to help physicians make the best treatment choice for each person.”
Dr. Linsenmeyer and colleagues set out to investigate how genes that affect the brain’s dopamine pathways could predict recovery in people with moderate-to-severe TBI. The team recruited 94 adults with TBI from a level-1 trauma center. They focused on the following five genes in the dopamine pathways: COMT rs4680, VMAT2 rs363226, DRD2 rs6279, ANKK1 Taq1a, and MAOA VNTR. They defined which risk genotypes were associated with lower average scores on surveys filled out by patients with TBI to describe their overall quality of life at six and 12 months after their injuries.
The researchers analyzed how individual variants of each of these five genes could affect patients’ quality of life, and then generated a weighted gene risk score as a measure to reflect cumulative risk represented by all genotypes included in the score. Based on available literature about dopamine pathway genetics, they predicted that their gene risk score calculation tool should be specific to a patient’s sex.
Before they calculated gene risk scores, the research team noticed that only COMT could significantly predict quality of life for a subset of patients six months after their injuries. After generating sex-specific gene risk scores, they found that variants of all five genes on the dopamine pathway could meaningfully contribute to a gene risk score that was highly predictive of quality of life after six months for patients of both sexes with TBI, and also predictive of quality of life after one year for women.
Electrical Stimulation Device Improves Motor Function
A person with a spinal cord injury can improve his or her ability to grip and move household objects by using an electrical stimulation device controlled by his or her thoughts, according to researchers. The study suggests that this new technology could one day enhance quality of life among people with disabilities and allow them to live more independently.
People with tetraplegia lose upper-limb strength and dexterity, which has a severe impact on their independence and quality of life. New technology that connects a person’s brain to an implanted functional electrical stimulation orthotics device on the hands could restore manual dexterity and grip strength, thus allowing him or her to perform simple daily tasks like holding a toothbrush without help.
“Individuals with cervical spinal cord injury identify recovery of the use of their hands as the single most impactful way that neurotechnology could change their lives,” said Marcie Bockbrader, MD, PhD, Assistant Professor of Physical Medicine and Rehabilitation at the Ohio State University Wexner Medical Center in Columbus. “Giving a person back [his or her] hands reduces dependence on others. It makes it possible to do the little things—like cutting food or opening a door—that are so essential to being able to take care of oneself.”
To test how well this thought-controlled brain–computer interface system works in real life to improve hand strength and dexterity, Dr. Bockbrader and her research team surgically implanted one of these devices into the hand of a 26-year-old man with C5-level, nonspastic tetraplegia following a spinal cord injury. He practiced using the device three times per week for four hours each session for more than 1,000 days. The research team administered standardized tests of upper-limb motor ability and functional participation to see how well the system improved his grip strength, quickness, and other basic skills.
Using this device improved the man’s upper-limb motor ability dramatically, according to several standardized tests. He improved his ability to grip and manipulate basic objects, and showed that he could perform ordinary tasks with his hands at the speed and dexterity levels of healthy individuals. He could move objects of different sizes and weights. With practice, he improved his ability to manipulate smaller household objects like a toothbrush or hairbrush. He also demonstrated that he could imagine different hand positions to proportionally adjust and control different hand movements.
“Our study demonstrated that patients with tetraplegia might be able to restore some of their skilled hand function with an implanted device that allows them to control movements with their own thoughts,” said Dr. Bockbrader. “Although this technology must be refined and tested before it can go from the laboratory to the public, it may one day offer people with disabilities a way to live and work more independently, and enable them to perform daily tasks.”
Concussion Recovery Varies Among Children
Not all children follow the same path to concussion recovery, nor do they have the same predictors for returning to normal activity, investigators reported. Their study also suggests that younger children should be considered separately from high-school students.
“Concussions are common among children, yet the literature is limited with regard to understanding trajectory of recovery after concussion, particularly in children with non-sports-related injuries and for younger children,” said Kaitlyn Chin, a second-year medical student at University of New England College of Osteopathic Medicine in Biddeford, Maine. “We were particularly interested in understanding how activity levels during recovery from concussion influence time to full recovery, to be able to identify modifiable factors to help guide concussion care. Previous studies have noted differences in the amount of time it takes children to recover from a concussion, and our team recently initiated a study to see if we can identify predictors associated with the amount of time between injury and when a child is medically cleared to return to activities which place the child at risk for reinjury.”
Ms. Chin’s team at Kennedy Krieger Institute in Baltimore reviewed the medical records of 178 children who were treated for concussions at an academically affiliated, rehabilitation-based clinic. The children had been medically cleared to return to play between September 2015 and February 2017. The children included in the study ranged in age from 6 to 17. A slight majority was younger than 14. Each child’s first visit to the clinic was within 60 days of his or her concussion.
The researchers reviewed each child’s record, noting when they had been approved to return to play. Then they looked at several other factors for each child, including sex, cause of the concussion (ie, sports or non-sports-related), number of symptoms, school attendance, and exercise status at the initial visit to the clinic. Finally, they considered these factors when the children were placed into two categories—children under 14 and children over 14—to examine potential differences related to age.
Ms. Chin’s team found that the number of symptoms affected how quickly all children were cleared to return to play. Fewer symptoms were associated with a faster return to play. For older children, male sex and higher level of exercise during recovery were associated with a faster return to play. For younger children, higher levels of exercise and school participation (eg, attending class and completing homework and tests) were associated with faster return to play.
Overall, this study shows that elementary and middle-school-aged children should be considered separately from high-school-aged students when considering risk factors for prolonged recovery from a concussion. Furthermore, Ms. Chin’s team found that school participation and exercise were not harmful and did not prolong recovery.
“Our study adds to the literature supporting that return to cognitive and safe physical activities while a child is still recovering from concussion does not prolong time to recovery,” said Ms. Chin. “Every child is different, and recovery is different for each concussion. [Therefore], a concussion recovery plan should be tailored for each child, and parents should seek help from the child’s pediatrician or other medical professionals for guiding care after a concussion.”
Medicine May Not Affect Concussion Recovery
Medications commonly prescribed to reduce symptoms of concussion may not affect recovery, said investigators. Sports medicine physicians commonly treat patients with concussion, so researchers in Utah investigated how some widely prescribed treatments might affect patients’ recovery.
“We really do not have much other than rest and gentle exercise to combat symptoms of concussion,” said Venessa Lee, MD, a physical medicine and rehabilitation resident at University of Utah Health in Salt Lake City. “Medications are commonly prescribed to help with symptoms, but there is little evidence that they help more than just time and rest.”
Although FDA has not approved any medication to treat concussion, physicians may prescribe medications like gabapentin or tricyclic antidepressants (TCAs) to help reduce symptoms during recovery. To examine whether these drugs benefit patients, Dr. Lee and her research team looked at 277 patients who had been diagnosed with concussion at a local academic sports medicine practice. At each of their visits to the clinic during recovery, patients reported their postconcussion symptoms. The research team used a score sheet to measure their symptoms, and they tracked scores of patients who had more than one visit to the clinic for as long as one year.
Patients were separated into three groups for the study: those not prescribed any medication, those prescribed gabapentin, and those prescribed one of two TCAs, amitriptyline or nortriptyline. Based on self-reported information, investigators gave each patient a score for two factors of postconcussion recovery: headaches and a combination of 22 symptoms, including headaches. Each score was on a scale of 0 to 6.
After they adjusted scores for gender and age, Dr. Lee’s team found that headache and combined symptoms scores decreased significantly within days after the first clinic visit for all three groups of patients—those who had taken no medications, those who had been prescribed gabapentin, and those who had been prescribed a TCA. Patients who had been prescribed any of the medications had significantly higher scores for headaches and overall postconcussion symptoms to begin with, but no one type of medication had any better or worse effect over the duration of the study.
“Patients’ symptoms improve with time after a concussion,” said Dr. Lee. “When we looked at [patients who received] gabapentin and TCAs, their symptoms improved over time as well, but similar to those that did not receive a medication.”
Based on this study, neither gabapentin nor TCAs appear to provide any additional benefit for postconcussion recovery. With this information, patients may be able to avoid taking unnecessary medications as they recover from concussions. Patients should speak with a physician about their symptoms after a concussion, said Dr. Lee.
“Though the two medications we studied did not show a profound improvement in our analysis, this was a retrospective study … which has many drawbacks and limitations. We need to do more research to really find the best method for improving postconcussive symptoms.”
Ballet Helps Children with Musculoskeletal and Neurologic Conditions
Adaptive ballet classes provide functional improvement and social interactions for children with musculoskeletal and neurologic conditions, according to researchers. This type of arts-based adaptive therapy is a promising expansion to successful adaptive sports therapies, said the investigators.
“While great strides have been made in adaptive sports, there are still relatively few opportunities in the arts for people with disabilities,” said Sarah Stauder, MD, a physician at the Medical College of Wisconsin in Milwaukee. “Because of this [scarcity], we wanted to evaluate the effect of adaptive ballet on the physical, emotional, social, and academic function of children with physical impairments. The program is a collaboration between a children’s hospital and a metropolitan ballet company that brings together professional dancers, pediatric doctors, physical and occupational therapists, and children with physical disabilities for a series of dance classes.”
The goal of the study was to see whether a weekly, 45-mintute ballet class with 15 minutes of ballet education over five consecutive weeks would improve the children’s balance, physical functions, social skills, and overall quality of life. Eighteen children (17 girls) from ages 5 to 14, took part in the class. Assessments of each child were performed before and after the series of classes using the Pediatric Quality of Life Inventory, the PEDI-CAT survey, and the Pediatric Balance Scale. Finally, a questionnaire was used to assess each child’s success in achieving individual goals set for the class.
At the end of the five weeks, 94% of participants reached their individual goals for the ballet program. PEDI-CAT scores improved after completion of the program, and the program was most beneficial to participants who had lower functioning and quality of life at the beginning of the program. Finally, the researchers noticed an average improvement in balance among the participants.
“Adaptive programs like the one studied here give children the opportunity to participate in activities they otherwise would have no way to do,” said Dr. Stauder. “More specifically, these dance classes instilled a sense of pride and confidence in the children while improving their physical functioning and quality of life. Our study should open the door to more arts-based therapy for children. It is an effective and enjoyable way for patients to get the therapy they need. When kids are active in an activity that interests them, they naturally make greater strides, and we were able to see this in their day-to-day function.”
Genetic Risk Score Predicts TBI Outcomes
A genetic risk score could help predict a patient’s quality of life after a traumatic brain injury (TBI), said researchers. One day, physicians could have a simple method to forecast a patient’s recovery and personalize therapy to maximize quality of life.
“Gene pathways can influence all of our biologic functions and risk for many health outcomes,” said Mark Linsenmeyer, MD, a resident physician at the University of Pittsburgh Medical Center. “Each person has a unique inherited genetic code. By studying one gene pathway in a large group of people with the same disease or health problem, we hope to unlock clues to why some people have different outcomes than others. This knowledge may be used to help physicians make the best treatment choice for each person.”
Dr. Linsenmeyer and colleagues set out to investigate how genes that affect the brain’s dopamine pathways could predict recovery in people with moderate-to-severe TBI. The team recruited 94 adults with TBI from a level-1 trauma center. They focused on the following five genes in the dopamine pathways: COMT rs4680, VMAT2 rs363226, DRD2 rs6279, ANKK1 Taq1a, and MAOA VNTR. They defined which risk genotypes were associated with lower average scores on surveys filled out by patients with TBI to describe their overall quality of life at six and 12 months after their injuries.
The researchers analyzed how individual variants of each of these five genes could affect patients’ quality of life, and then generated a weighted gene risk score as a measure to reflect cumulative risk represented by all genotypes included in the score. Based on available literature about dopamine pathway genetics, they predicted that their gene risk score calculation tool should be specific to a patient’s sex.
Before they calculated gene risk scores, the research team noticed that only COMT could significantly predict quality of life for a subset of patients six months after their injuries. After generating sex-specific gene risk scores, they found that variants of all five genes on the dopamine pathway could meaningfully contribute to a gene risk score that was highly predictive of quality of life after six months for patients of both sexes with TBI, and also predictive of quality of life after one year for women.
