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Research Blog

Does Vestibular-Ocular-Motor Impairment Affect Time to Return to Play, Symptom Severity, Neurocognition and Academic Ability in Student Athletes Following Acute Concussion?

Summarized by Dr. Ally Ferber, MD

February 2024

The article talks about athletes who experience a concussion while playing sports. A concussion is a type of brain injury that can happen when the head is hit hard or moves very quickly. This impact can lead to changes in how the brain works, affecting the cells (neurons) and causing different symptoms.

The article focuses on symptoms related to the vestibular-ocular-motor (VOM) system and how they impact an athlete’s return to sports and school performance. The VOM system involves balance, vision, and movement. If this system is disrupted, it can cause issues like dizziness, nausea, blurred vision, and difficulty reading.

Testing for problems in the VOM system isn’t common yet, but the article suggests it could be helpful. Using a screening tool to identify athletes with balance, vision, and movement issues, they found that those with symptoms in this system took longer to recover, had more severe symptoms, missed more school, and needed more time overall to get better.

In summary, using the VOM screening tool in the first two weeks after a sports-related concussion might help doctors identify athletes with specific issues. This can give athletes and their families an idea of how long the recovery might take, when they can return to sports, and when they can go back to school. It also allows doctors to recommend specific exercises to help athletes heal better.

https://pubmed.ncbi.nlm.nih.gov/33896286/

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Determination of Calorie and Protein Intake Among Acute and Sub-Acute Traumatic Brain Injury Patients

Summarized by Teja Makkapati, MD

January 2024

When someone ends up in the hospital, there is a high chance they might not be getting the right amount of nutrition, especially if they have experienced a traumatic brain injury (TBI). TBIs require extra nutrients for the brain to heal properly. Studies suggest that a large number of hospitalized patients, about 20-50%, end up malnourished, however there is not much research on how this specifically affects TBI patients.

For people with TBIs , their bodies go into overdrive trying to heal the brain. This means they need more calories and protein than usual. The study “Determination of calorie and protein intake among acute and sub-acute traumatic brain injury patients” looked at the dietary habits of 50 TBI patients to see how well they were eating during their hospital stay. They looked at their daily food intake, considering things like body mass index (BMI), age, and gender in their calculations.

The results showed that the more severe the TBI, the less people ate. Even though eating improved a bit over time, it still was no’t enough to meet their calorie needs. The most common reasons for this are pain, discomfort, and emotional issues after the injury which makes individuals want to eat less.

In summary, people with TBIs are not getting the nutrition they need, and those with more severe injuries are at a higher risk of developing malnutrition. This is a population at high risk of being malnourished and more studies are needed to find ways to help these patients get the right nutrition during their hospital stay for a quicker recovery.

https://pubmed.ncbi.nlm.nih.gov/32423779/

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The Utility of Melatonin for the Treatment of Sleep Disturbance After Traumatic Brain Injury: A Scoping Review

Summarized by Dr. Hannah Park

December 2023

Poor sleep is very common after a traumatic brain injury (TBI), and it affects more than 50% of patients. These sleep disturbances can include less total time sleeping, waking up from sleep more frequently, having poor quality sleep, and not feeling well-rested after sleep. Insomnia, or difficulty falling asleep, is the most common sleep disorder seen after a TBI and affects 50-70% of patients.

The reason why sleep disturbances develop after a TBI is not fully understood, but several theories include changes in hormones that affect our sleep/wake cycle, including melatonin and orexin/hypocretin. Also, TBI patients can develop mood disorders like anxiety and depression that makes it more difficult to get good quality sleep. Melatonin is a hormone naturally produced in the brain by the pineal gland. It has been used to help treat patients with circadian rhythm disorders such as insomnia, and it has been shown to improve the quality of sleep, how long it takes to fall asleep, and reducing waking up during the night.

The Utility of Melatonin for the Treatment of Sleep Disturbance After Traumatic Brain Injury: A Scoping Review. This study from 2023 looked at other research articles studying melatonin use after TBI, and they chose 9 articles to evaluate with a total of 251 participants including adults and kids. These studies were from all around the world and included all severities of TBI, from mild to severe. For the medications, they used either melatonin, Circadin (an melatonin that is slowly released throughout the day), or Ramelton (a drug that activates melatonin receptors) at doses between 2 to 10mg, and they took these medications for 3 to 12 weeks.

8 out of the 9 studies reported positive outcomes after melatonin treatment. Overall, patients had improved sleep duration, sleep quality, and daytime alertness. Melatonin also improved some mental health symptoms (anxiety and depression), cognitive function, and memory. Patients who had worse sleep patterns before starting melatonin had better responses. There were no serious adverse events with treatment of melatonin in adults and children up to doses of 10mg.

Interestingly, the medications studied caused some TBI patients to take the same amount of time to fall asleep or even more time to fall asleep by up to 5 minutes. This is different from other studies in non-TBI patients, where the medications helped patients to fall asleep more quickly. More research needs to be done to further examine this effect of the melatonin medications.

In conclusion, sleep disturbances are commonly seen after TBI, especially mild TBI. They can last for several years after an injury and make recovery more difficult because the brain doesn’t get proper rest and time to heal. Feeling tired during the day can also make it more difficult to participate in the therapies that will help with recovery. Melatonin and its related medications can help to reduce the effects and symptoms of sleep disturbances and has been well-tolerated in adults and kids. We need to do more research comparing the efficacy of these medications with other interventions like cognitive behavioral therapy, improved sleep hygiene, and alternative medications. For now, if you have a loved one who is suffering from sleep disturbances after TBI, it is reasonable to try adding melatonin under the direction of your doctors.

https://pubmed.ncbi.nlm.nih.gov/36243124/

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Rehabilitation of Social Communication Skills in Patients with Acquired Brain Injury with Intensive and Standard Group Interactive Structured Treatment: A Randomized Controlled Trial

Summarized by Dr. Jessie Chan
November 2023

A recent article titled, “Rehabilitation of Social Communication Skills in Patients with Acquired Brain Injury with Intensive and Standard Group Interactive Structured Treatment: A Randomized Controlled Trial” was published in the Archives of Physical Medicine and Rehabilitation by authors Ingebresten et al. People with brain injuries often have trouble with social communication, which makes it hard for them to fit back into their community. This can lead to loneliness and difficulty with making friends or finding and keeping a job.

Past studies showed that a treatment done once a week for 3 months can help people with acquired brain injuries communicate better and feel happier in their day-to-day lives. The treatment includes group activities, help with setting personal goals, homework, and active feedback. It helps with parts of communication like understanding what other people are thinking and not saying inappropriate things. There is not a lot of information on how long or often treatments should be, so the authors did an earlier study to test how well the same treatment done every day for one month would help patients. It showed that this shortened and frequent treatment worked about as well as the original treatment.

This study compared two groups of people in Norway who had acquired traumatic or nontraumatic brain injuries. Group A got standard treatment which was once a week for 3 months in an outpatient clinic. Group B was first put on a waitlist without treatment for social communication for 9 months. This created a “no treatment” group to compare against. Group B then had intensive treatment which was every day for one month in an inpatient cognitive rehabilitation unit. This group of patients were encouraged to go home on weekends during treatment to practice their skills in real life with friends and family. The results showed that both the standard and intensive treatments helped people with brain injuries communicate better compared to no treatment. At the end of the study, Group A and Group B had equal improvements in social communication skills, even when they were retested 6 months later.

It seems that standard outpatient and intensive inpatient social communication treatment are both good options for people with acquired injuries to communicate better. One factor to think about is that intensive inpatient treatment can be harder to find, but it could be a good option for people who have fewer friends and family to practice social skills with or would have trouble getting to the outpatient clinic every week. This study shows that both kinds of treatments can help acquired brain injury patients with improving social communication, even if it has been a long time since the injury happened.

For more information read the entire article https://pubmed.ncbi.nlm.nih.gov/36966953/

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Early Initiation of Vestibular Therapy Following Sports-Related Concussions: A Retrospective Cohort Study

Summarized by Arielle Berkowitz, DO
November 2023

When a player experiences a bump to the head during a sports game or practice, he/she may begin to experience headaches, dizziness, blurred vision, trouble concentrating, or a brief loss of consciousness known as a Sports Related Concussion (SRC). These symptoms are often troubling and may make it difficult to immediately return to school, work, and/or sports. SRC can occur at any age and at any level of athletic training.

Recovery after a SRC is different for each individual. Athletes who are female, who have had prior concussions, learning disabilities, and/or psychiatric illness may have more trouble returning to their normal daily activities. During this tough time, it is important to follow with experts who can help with the recovery process and provide education, guidance, and encouragement.

In the past, it was recommended that athletes who have sustained a SRC completely rest their minds and body- avoiding television, phones, computers, and school-work- so that their brains could fully heal. More recent guidelines advise light activity/work during this recovery period. In most states, athletes are required to progress through a daily exercise schedule with a trained professional for one whole week. During this time, the athlete must perform exercises with increasing intensity with close monitoring of symptoms.

Vestibular therapy is a therapy that is often offered to patients who continue to experience symptoms such as dizziness and balance issues weeks after their injury. With vestibular therapy, patients work closely with physical therapists to improve things such as balance and vision. In a recent article, “Early Initiation of Vestibular Therapy Following Sport-Related Concussions: A Retrospective Cohort Study,” by Ferry et al., the authors wanted to determine whether or not starting vestibular therapy shortly after injury would result in a faster recovery. In this study, the researchers reviewed the medical charts of patients ages 12-25 years who had a SRC between January 2014-December 2019, were seen in the Sports Medicine Concussion Clinic at Duke University and were referred to PT for vestibular therapy.

Results from this study suggested that waiting to start vestibular therapy could increase the time to recovery and return to sport. In other words, starting vestibular therapy early after injury could result in a quicker recovery. After SRC, it is important to seek appropriate care early. Although we still need more details regarding exactly how long a person should receive vestibular therapy, how frequently he/she should go for visits, and when to begin the therapy, it is noted that, overall, it is extremely helpful without any detrimental effects.

For more information view the article https://doi.org/10.7759/cureus.39764

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Perspective: Cognitive Behavioral Therapy for Insomnia Is a Promising Intervention for Mild Traumatic Brain Injury

Summarized by Dan Zhou, MD
October 2023

Insomnia is one of the most common complaints after traumatic brain injury. It occurs in almost half of patients and is more common in those with mild injuries, also known as concussions. People with insomnia have difficulty falling and staying asleep at night. This can negatively affect day-to-day routines due to tiredness and difficulty concentrating. A recent article titled “Perspective: Cognitive Behavioral Therapy for Insomnia Is a Promising Intervention for Mild Traumatic Brain Injury” was published in Frontiers in Neurology which reviews cognitive-behavioral therapy for insomnia (CBT-I) in concussion patients.

CBT-I uses a combined cognitive and behavioral approach to treatment. Some examples include concepts such as limiting stimulation at bedtime, relaxation training, cognitive therapy, and sleep hygiene training. The overall goal is to promote sleep at bedtime, improve the sleep/wake cycle, and address negative thoughts surrounding sleep which would decrease sleep-related anxiety and arousal. In treatment trials, CBT-I has emerged as the preferred treatment for insomnia. The article mentions that 70-80% of patients with insomnia experience lasting benefit from CBT-I and about half have complete resolution.

Similar to treating insomnia in general, CBT-I is also preferred as the main treatment for insomnia in concussion patients. Compared to taking prescription medications or self-treating, CBT-I does not have the side effects that all medications may carry and can provide lasting benefits. To understand why CBT-I is most appropriate for insomnia after concussion, we need to understand the connection between the two. The leading theory of why insomnia happens frequently after concussion is discussed in the article. First some people are at risk be it through their genetics or personalities. This is followed by a trigger which would be the head injury.

The last factor is the perpetuating loop that keeps the sleep issues going. This loop is due to changes in behavior and attitudes. For instance, some people may attempt to sleep longer by taking more naps during the day which can mess up normal sleep patterns. Additionally, having negative thoughts like “lack of sleep will negatively affect my recovery” causes a cycle of anxiety associated with sleep. It is specifically this perpetuating loop phase with all of its behavioral and emotional factors where CBT-I may have the greatest benefit. Improving sleep after concussion is important as it is shown to improve mental functioning, pain, depression, and anxiety. These are some of the reasons that CBT-I has been and remains promising for the treatment of insomnia in mild traumatic brain injury patients.

 

For more information, view the article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7575746/

 

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Effects of Exercise Programs on Functional Capacity and Quality of Life in People With Acquired Brain Injury

Summarized by Meaghan Dowdell, SPT
August 2023

When someone experiences a brain injury, they may become more likely to lead a lifestyle with little physical activity, which can affect their independence and the things they enjoy doing, making life less fulfilling.

But, there’s good news! Taking part in a supervised exercise program after a brain injury can actually help improve both the physical and mental aspects of health. A study done in 2022 by Pérez-Rodríguez and colleagues looked at different types of exercises and how much people did them, finding out what helped the most for those with brain injuries.

They studied adults with brain injuries who did exercises like aerobics, strength training, or a mix of both for about 12 weeks. The exercises ranged from one to seven times a week, lasting between 30 to 120 minutes each time. They checked how these exercise programs affected things like balance, endurance, and mobility, as well as how people felt about themselves and their social interactions.

The big discovery was that no matter what type of exercise they did, those who stuck to the programs saw positive changes. It means that they improved in all those areas we mentioned before, which makes life better and more enjoyable after a brain injury.

So, it’s suggested that people with brain injuries should join supervised exercise programs that they can easily do and enjoy. Activities like walking, swimming, cycling, yoga, or weight lifting can be great choices. And having friends or family support you during these activities is a big plus!

Before starting any exercise program, it’s a good idea to check with a physical therapist or health care professional. They can make sure the exercises are safe and suitable for you and your goals. When you find exercises that you like and find important, it becomes easier to make them a part of your regular routine. This helps improve your life and health after a brain injury. 

 For more detailed information on the studies included in this review and the outcome measures performed, here is the link for the full article: https://doi.org/10.1093/ptj/pzac153   

  

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