Background
Headache is one of the most common and persistent symptoms following traumatic brain injury (TBI). The current study examines the prevalence and characteristics of headache following mild ...TBI (mTBI).
Methods
We prospectively enrolled 212 subjects within one week of mTBI who were hospitalized for observation or other system injuries in a single level 1 US trauma center and followed by telephone at three, six, and 12 months after injury for evaluation of headache. Headaches were classified according to ICHD-2 criteria as migraine, probable migraine, tension-type, cervicogenic, or unclassifiable headache.
Results
Subjects were 76% male and 75% white, and 58% were injured in vehicle-related crashes. A follow-up rate of 90% (190/212) occurred at 12 months post-injury. Eighteen percent (38/212) of subjects reported having a problem with headaches pre-injury while 54% (114/210) of subjects reported new or worse headaches compared to pre-injury immediately after injury, 62% (126/203) at three months, 69% (139/201) at six months, and 58% (109/189) at one year. Cumulative incidence was 91% (172/189) over one year. Up to 49% of headaches met criteria for migraine and probable migraine, followed by tension-type headaches (up to 40%). Age (≤ 60) was found to be a risk factor, but no significant difference was found in persistence of new or worse headache compared to pre-injury between males and females. More than one-third of the subjects reported persistent headache across all three follow-up time periods.
Conclusions
Headache after mTBI is very common and persistent across the first year after injury. Assertive, early treatment may be warranted to avoid chronicity and disability. Further research is needed to determine whether post-traumatic headache (PTH) responds to headache treatment used in the primary headache disorders and whether chronic PTH is preventable.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
The autonomic nervous system (ANS) plays a vital role in maintaining and regulating homeostatic processes. ANS dysfunction has been reported in patients with moderate to severe traumatic brain injury ...(TBI), but its role in mild TBI (mTBI) is understudied. The objective of this review is to elucidate the role of ANS dysfunction following mTBI and the underlying pathophysiology specifically neuroinflammation, neurodegeneration, oxidative stress, and altered cerebral blood flow.
ANS dysfunction is thought to be one of the many factors contributing to clinical features following mTBI including headache, anxiety, cognitive impairment, mood disorders, and sleep disturbances. The ANS has been shown to play a role in the production and regulation of pro-inflammatory molecules. ANS dysfunction most often results in exaggerated sympathetic neural activation (SNA) which contributes to neuroinflammation and oxidative stress. SNA is associated with the production of reactive oxygen species and subsequent neurodegeneration following mTBI. Additionally, changes in cerebral blood flow can be seen in patients with mTBI showing evidence of ANS dysfunction. No Level I studies have explored the relationship between mTBI and ANS dysfunction. Better understanding of the role of the ANS in mTBI will improve the evaluation and clinical management of mTBI by offering additional diagnostic and novel treatment strategies.
Sleep Disturbance After TBI Barshikar, Surendra; Bell, Kathleen R.
Current neurology and neuroscience reports,
11/2017, Volume:
17, Issue:
11
Journal Article
Peer reviewed
Purpose of Review
Present relevant literature to update knowledge on sleep science, identify common sleep disturbances seen in TBI, discuss evidence for available treatment options, and illuminate ...future areas for research.
Recent Findings
Sleep disturbances, including insomnia, circadian rhythm disturbances, and sleep apnea, are prevalent for all severities of traumatic brain injury (TBI), can be chronic, and affect both rehabilitation and recovery from the TBI.
Summary
New knowledge of basic sleep mechanisms and neurochemistry has exploded in the last decade. In addition to known effects on mood and cognition from sleep deprivation in persons with TBI, new evidence indicates potential deleterious effects on neurorecovery and acceleration of long-term neurodegeneration.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Although physiological deficits such as altered cerebral blood flow (CBF), and autonomic nervous system (ANS) dysregulation have been reported following a concussion, the relationship between CBF and ...ANS with functional outcome post-injury remains unclear. Our present study was designed to examine heart-rate variability (HRV) using percentage of successive NN intervals (pNN50) and CBF on day-3 (T1), day-21 (T2), and day-90 (T3) following a concussion in collegiate athletes (N = 31) in comparison to non-injured controls (N = 31). Continuous RR-interval (3-lead electrocardiogram), middle cerebral artery blood velocity (MCAV; transcranial Doppler ultrasonography), mean arterial pressure (MAP; finger photoplethysmography) were obtained at rest. Cerebrovascular conductance index (CVCi) was estimated as a ratio of MCAV to MAP. Cognition was evaluated with standard assessment of concussion (SAC), and Trails A & B. Compared to the controls, lower HRV (43 ± 15 vs. 27 ± 20%; p < 0.0001) was observed at T1 with normalization at T2 and T3. No difference in MCAV between the control and the concussed groups across the three time points were observed. However, post-hoc analyses indicated a positive relationship between MCAV at T1 phase with HRV and CVCi during T2, and T3 phases. Higher MCAV at T1 was also associated with better cognition scores during the asymptomatic T2 phase in the concussed athletes. Therefore, our results indicate ANS dysregulation during the acute recovery phase after a concussion. Differences in CBF may be one of the underlying causes behind heterogeneity in clinical symptoms and functional outcomes after a concussion and future studies are warranted to validate this finding.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Objectives
The primary outcome of this study was to assess the efficacy and safety of preventive treatment with amitriptyline on headache frequency and severity after mild traumatic brain injury ...(mTBI).
Background
Despite the fact that headache is the most common and persistent physical symptom after TBI, there has been little research on the longitudinal course or pharmacologic treatment of this disorder. Of those who have headache after injury, about 60% continue to complain of headache at 3 months post injury, with higher levels of disability than those without headache. There have been no prospective, randomized, controlled trials of a pharmacologic agent for headache after TBI. Additionally, a brain‐injured population may be more susceptible to side effects of medication.
Design
This is a single‐center phase II trial of amitriptyline to prevent persistent headache after an mTBI. Medication dose was gradually increased from 10 to 50 mg daily.
Results
Fifty participants were enrolled and 33 who completed the 90‐day assessment were included in the final analysis. In order to detect a possible cognitive impact of the study drug, 24 participants were randomly assigned to start amitriptyline immediately after study enrollment and 26 were assigned to start 30 days after enrollment. Forty‐nine percent (18/37) of those assigned to take medication took none throughout the study period, with less compliance in younger participants with mean ages of 32.7 in those who did not take any medication, 33.4 who were less than 80% compliant, and 42.3 who were compliant (P = .013). Compliance in keeping a daily headache diary was low, with 29/50 participants (58%) meeting daily entry completion, and only 10 participants maintaining 100% diary completion. No differences were found between those who started medication immediately vs at day 30 in headache frequency or severity.
Conclusions
While headache is the most common symptom following mTBI, current evidence does not support a specific treatment. No differences were noted in headache frequency compared to our prior study. However, the current sample had significantly lower headache severity (15% vs 36% with pain rating of 6 or above, P = .015) compared to our prior study. Our current study was not able to determine whether there is any benefit for the use of amitriptyline as a headache preventive because of difficulty with study recruitment and compliance. The challenges with recruitment and retention in the mTBI population were instructive, and future research in this area will need to identify strategies to improve recruitment, diary compliance, and medication adherence in this population.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
To determine the cross-sectional and temporal relationships between minutes per week of moderate to vigorous physical activity (MVPA) as measured by a wrist-worn accelerometer and secondary ...conditions in the first year after moderate to severe traumatic brain injury (TBI).
Prospective longitudinal cohort study.
Four inpatient rehabilitation centers.
Individuals (N = 180) with moderate-severe TBI enrolled in the TBI Model Systems Study.
Participants wore a wrist accelerometer for 7 days immediately post discharge, and for 7 consecutive days at 6- and 12-months post injury.
Minutes per week of MVPA from daily averages based on wrist worn accelerometer. Secondary conditions included depression (Patient Health Questionnaire-9), fatigue (PROMIS Fatigue), Pain (Numeric Rating Scale), Sleep (Pittsburgh Sleep Quality Index), and cognition (Brief Test of Adult Cognition by Telephone).
At baseline, 6 and 12 months, 61%, 70% and 79% of the sample achieved at least 150 minutes per week of MVPA. The correlations between minutes of MVPA between baseline, 6 and 12 months were significant (r = 0.53-0.73), as were secondary conditions over these time points. However, no significant correlations were observed between minutes of MVPA and any secondary outcomes cross-sectionally or longitudinally at any time point.
Given the robust relationships physical activity has with outcomes in the general population, further research is needed to understand the effect of physical activity in individuals with moderate-severe TBI.
Changes in federal policy during the COVID-19 pandemic allowing for the use of telemedicine to treat opioid use disorder (OUD) have facilitated innovative strategies to engage and retain people in ...treatment. Since 2018, the Baltimore City Health Department has operated a mobile street medicine program called Healthcare on The Spot (The Spot) that provides treatment for OUD and infectious diseases. This study describes the transition of The Spot’s buprenorphine service to telemedicine during the COVID-19 pandemic and one year treatment retention.
Patients actively engaged in care at the time of transition to telemedicine and patients newly engaged in buprenorphine services through telemedicine were included in this descriptive analysis and assessed at one year for retention.
From March 16, 2020 to March 15, 2021, The Spot provided voice-only buprenorphine treatment services to 150 patients, 70.7% (n = 106) male and 80.0% (n = 120) Black; 131 were patients who transitioned from in person services and 19 were newly engaged via telemedicine. 80.7% (n = 121) of patients remained engaged in treatment at one year, 16.0% (n = 24) were lost to follow-up, and 3.3% (n = 5) were deceased. Patients newly engaged via telemedicine were more likely to be female and white than those retained from in person services.
The Spot’s transition of patients from a street medicine program to telemedicine during the COVID-19 pandemic has implications for future practice. Increased flexibility of service delivery, extended prescription length, and decreased UDT likely contributed to high retention rates and should inform the future structure of low-threshold buprenorphine programs.
•Telemedicine can drive innovations in OUD service delivery.•80% of patients were retained in telemedicine buprenorphine treatment at one year.•Majority of patients were male and African American.•Decreased toxicology screening likely led to higher retention rates.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Headache is one of the most frequently reported symptoms following traumatic brain injury (TBI). Little is known about how these headaches change over time. We describe the natural history of ...headache in individuals with moderate to severe TBI over 5 years after injury. A total of 316 patients were prospectively enrolled and followed at 3, 6, 12, and 60 months after injury. Individuals were 72% male, 73% white, and 55% injured in motor vehicle crashes, with an average age of 42. Pre-injury headache was reported in 17% of individuals. New or worse headache prevalence remained consistent with at least 33% at all time points. Incidence was >17% at all time points with first report of new or worse headache in 20% of participants at 60 months. Disability related to headache was high, with average headache pain (on 0-10 scale) ranging from 5.5 at baseline to 5.7 at 60 months post-injury, and reports of substantial impact on daily life across all time points. More than half of classifiable headaches matched the profile of migraine or probable migraine. Headache is a substantial problem after TBI. Results suggest that ongoing assessment and treatment of headache after TBI is needed, as this symptom may be a problem up to 5 years post-injury.
Abstract Fogelberg DJ, Hoffman JM, Dikmen S, Temkin NR, Bell KR. Association of sleep and co-occurring psychological conditions at 1 year after traumatic brain injury. Objectives To compare ...individuals' sleep 1 year after traumatic brain injury (TBI) with that of a healthy comparison group, and examine the relationship between sleep, co-occurring conditions, and functional status in those with TBI. Design Longitudinal assessment of a prospectively studied sample of individuals with moderate to severe TBI. Assessment of sleep occurred at 1 year after TBI. Setting Inpatient acute rehabilitation for TBI and community follow-up at 1 year postinjury. Participants Individuals with TBI (N=174) were recruited from consecutive admissions to an inpatient rehabilitation unit and enrolled into the TBI Model Systems study. Participant mean age was 38, and mean Glasgow Coma Scale score on admission was 9.3. Seventy-eight percent of the sample were men. Interventions None. Main Outcome Measures Sleep was assessed with the Pittsburgh Sleep Quality Index (PSQI). Depression, anxiety, and pain were measured with the Patient Health Questionnaire-9, the Generalized Anxiety Disorder-7 Scale, and an analog pain rating scale, respectively. Results Participants with TBI reported significantly greater sleep difficulties than the healthy comparison group. Forty-four percent of participants with TBI reported significant sleep problems (PSQI>5). Participants with 1 or more co-occurring conditions (depression, pain, or anxiety) had significantly worse sleep than those without such a condition. The highest level of sleep problems was reported by participants with multiple co-occurring conditions. Sleep problems were also associated with poor functional status. Conclusions Sleep difficulties are a frequent problem at 1 year after TBI, and often co-occur with depression, anxiety, and pain. Assessment and treatment of sleep difficulties should be included in clinical practice. Future research on the potential causal relationship among co-occurring conditions may assist in additional intervention planning.
Abstract Wise EK, Hoffman JM, Powell JM, Bombardier CH, Bell KR. Benefits of exercise maintenance after traumatic brain injury. Objective To examine the effect of exercise intervention on exercise ...maintenance, depression, quality of life, and mental health at 6 months for people with traumatic brain injury (TBI) with at least mild depression. Design Treatment group participants were assessed at baseline, after a 10-week exercise intervention, and 6 months after completion of the intervention. Setting Community. Participants Participants (N=40) with self-reported TBI from 6 months to 5 years prior to study enrollment and a score of 5 or greater on the Patient Health Questionnaire-9. Interventions Ten-week exercise intervention program consisting of supervised weekly 60-minute sessions and unsupervised 30 minutes of aerobic exercises 4 times each week. Telephone follow-up was conducted every 2 weeks for an additional 6 months to promote exercise maintenance for individuals randomized to the intervention group. Main Outcome Measure Beck Depression Inventory (BDI) comparing participant outcomes over time. Post hoc analyses included comparison among those who exercised more or less than 90 minutes per week. Results Participants reduced their scores on the BDI from baseline to 10 weeks and maintained improvement over time. Many participants (48%) demonstrated increased physical activity at 6 months compared with baseline. Those who exercised more than 90 minutes had lower scores on the BDI at the 10-week and 6-month assessments and reported higher perceived quality of life and mental health. Conclusions Exercise may contribute to improvement in mood and quality of life for people with TBI and should be considered as part of the approach to depression treatment.
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