Comparisons between Locomat and Walkbot robotic gait training regarding balance and lower extremity function among non-ambulatory chronic acquired brain injury survivors.

ABSTRACT: Lower limb rehabilitation exoskeleton robots connect with the human body in a wearable way and control the movement of joints in the gait rehabilitation process. Among treadmill-based lower limb rehabilitation exoskeleton robots, Lokomat (Hocoma AG, Volketswil, Switzerland) has 4 actuated joints for bilateral hips and knees whereas Walkbot (P&S Mechanics, Seoul, Korea) has 6 bilateral actuated joints for bilateral hips, knees, and ankles. Lokomat and Walkbot robotic gait training systems have not been directly compared previously. The present study aimed to directly compare Lokomat and Walkbot robots in non-ambulatory chronic patients with acquired brain injury (ABI).The authors conducted a single-center, retrospective, cross-sectional study of 62 subjects with ABI who were admitted to the rehabilitation hospital. Patients were divided into 2 groups: Lokomat (n = 28) and Walkbot (n = 34). Patients were subjected to robot-assisted gait training (RAGT) combined with conventional physical therapy for a total of 14 (8-36) median (interquartile range) sessions. Baseline characteristics, including age, sex, lag time post-injury, ABI type, paralysis type, intervention sessions, lower extremity strength, spasticity, and cognitive function were assessed. Functional ambulation category (FAC) and Berg balance scale (BBS) were used for outcome measures.There were no significant differences in baseline characteristics between the groups. Baseline FAC score was 1 (0-2) in Lokomat and 1 (0-1) in Walkbot group. After the intervention, FAC scores improved significantly to 2 (1-3) in both groups (P < .05). Lokomat and Walkbot groups showed significantly enhanced BBS from 5 (2.75-24.25) and 15 (4-26.5) to 15 (4-26.5) and 22 (12-40), respectively (P < .05). Degree of improvements in both group were not significantly different with regard to balance (P = .56) and ambulatory ability (P = .74).This study indicates that both Locomat and Walkbot robotic gait training combined with conventional gait-oriented physiotherapy are promising intervention for gait rehabilitation in patients with chronic stage of ABI who are not able to walk independently.

Concussion in Chronic Traumatic Encephalopathy.

Chronic traumatic encephalopathy (CTE) is a progressive neurodegenerative disease that occurs in association with repetitive mild traumatic brain injury. It is associated with a variety of clinical symptoms in multiple domains, and there is a distinct pattern of pathological changes. The abnormal tau pathology in CTE occurs uniquely in those regions of the brain that are likely most susceptible to stress concentration during trauma. CTE has been associated with a variety of types of repetitive head trauma, most frequently contact sports. In cases published to date, the mean length of exposure to repetitive head trauma was 15.4 years. The clinical symptoms of the disease began after a mean latency of 14.5 years with a mean age of death of 59.3 years. Most subjects had a reported history of concussions with a mean of 20.3. However, 16 % of published CTE subjects did not have a history of concussion suggesting that subconcussive hits are sufficient to lead to the development of CTE. Overall, the number of years of exposure, not the number of concussions, was significantly associated with worse tau pathology in CTE. This suggests that it is the chronic and repetitive nature of head trauma, irrespective of concussive symptoms, that is the most important driver of disease. CTE and exposure to repetitive head trauma is also associated with a variety of other neurodegenerations, including Alzheimer disease. In fact, amyloid ß peptide deposition is altered and accelerated in CTE and is associated with worse disease. Here, we review the current exposure, clinical, and pathological associations of CTE.

Current topics in sports-related head injuries: a review.

We review the current topic in sports-related head injuries including acute subdural hematoma (ASDH), concussion, and chronic traumatic encephalopathy (CTE). Sports-related ASDH is a leading cause of death and severe morbidity in popular contact sports like American football in the USA and judo in Japan. It is thought that rotational acceleration is most likely to produce not only cerebral concussion but also ASDH due to the rupture of a parasagittal bridging vein, depending on the severity of the rotational acceleration injury. Repeated sports head injuries increase the risk for future concussion, cerebral swelling, ASDH or CTE. To avoid fatal consequences or CTE resulting from repeated concussions, an understanding of the criteria for a safe post-concussion return to play (RTP) is essential. Once diagnosed with a concussion, the athlete must not be allowed to RTP the same day and should not resume play before the concussion symptoms have completely resolved. If brain damage has been confirmed or a subdural hematoma is present, the athlete should not be allowed to participate in any contact sports. As much remains unknown regarding the pathogenesis and pathophysiology of sports-related concussion, ASDH, and CTE, basic and clinical studies are necessary to elucidate the crucial issues in sports-related head injuries.

Is chronic traumatic encephalopathy a real disease?

Chronic traumatic encephalopathy (CTE) has received widespread media attention and is treated in the lay press as an established disease, characterized by suicidality and progressive dementia. The extant literature on CTE is reviewed here. There currently are no controlled epidemiological data to suggest that retired athletes are at increased risk for dementia or that they exhibit any type of unique neuropathology. There remain no established clinical or pathological criteria for diagnosing CTE. Despite claims that CTE occurs frequently in retired National Football League (NFL) players, recent studies of NFL retirees report that they have an all-cause mortality rate that is approximately half of the expected rate, and even lower suicide rates. In addition, recent clinical studies of samples of cognitively impaired NFL retirees have failed to identify any unique clinical syndrome. Until further controlled studies are completed, it appears to be premature to consider CTE a verifiable disease.

Chronic traumatic encephalopathy and suicide: a systematic review.

Traumatic brain injury (TBI) is a global health concern, and the recent literature reports that a single mild TBI can result in chronic traumatic encephalopathy (CTE). It has been suggested that CTE may lead to death by suicide, raising important prevention, treatment, and policy implications. Thus, we conducted a systematic review of the medical literature to answer the key question: What is the existing evidence in support of a relationship between CTE and suicide? Systematic searches of CTE and suicide yielded 85 unique abstracts. Seven articles were identified for full text review. Only two case series met inclusion criteria and included autopsies from 17 unique cases, 5 of whom died by suicide. Neither studies used blinding, control cases, or systematic data collection regarding TBI exposure and/or medical/neuropsychiatric history. The identified CTE literature revealed divergent opinions regarding neuropathological elements of CTE and heterogeneity regarding clinical manifestations. Overall quality of evidence regarding a relationship between CTE and suicide was rated as very low using Grading of Recommendations Assessment, Development and Evaluation Working Group (GRADE) criteria. Further studies of higher quality and methodological rigor are needed to determine the existence and nature of any relationship between CTE and suicide.

Outcome after severe brain trauma due to acute subdural hematoma.

OBJECT: In this paper, the authors' goal was to identify factors contributing to outcomes after severe traumatic brain injury (TBI) due to acute subdural hematoma (SDH). METHODS: Between February 2002 and April 2010, 17 Austrian centers prospectively enrolled 863 patients with moderate and severe TBI into observational studies. Data regarding accident, treatment, and outcomes were collected. Data sets from patients who had severe TBI (Glasgow Coma Scale score < 9) and acute SDH were selected. Six-month outcomes were classified as "favorable" if the Glasgow Outcome Scale (GOS) scores were 5 or 4, and they were classified as "unfavorable" if GOS scores were 3 or less. The Rotterdam score was used to classify CT findings, and the scores published by Hukkelhoven et al. were used to estimate the predicted rates of death and of unfavorable outcomes. Univariate (Fisher exact test, t-test, chi-square test) and multivariate (logistic regression) statistics were used to identify factors associated with hospital mortality and favorable outcome. RESULTS: Of the 738 patients with severe TBI, 360 (49%) had acute SDH. Of these, 168 (46.7%) died in the hospital, 67 (18.6%) survived with unfavorable outcome, and 116 (32.2%) survived with favorable outcome. Long-term outcome was unknown in 9 survivors (2.5%). Mortality rates predicted by the Rotterdam CT score showed good correlation with observed mortality rates. According to the Hukkelhoven scores, observed/predicted ratios for mortality and unfavorable outcome were 1.09 and 1.02, respectively. CONCLUSIONS: Age, severity of TBI, and neurological status were the main factors influencing outcomes after severe TBI due to acute SDH. Nonoperative management was associated with significantly higher mortality.

Is direct transport to a trauma centre best for patients with severe traumatic brain injury? A study in south-central Taiwan.

OBJECTIVE: This study attempted to identify any differences between the outcomes of patients with severe traumatic brain injury (TBI) who were directly transported to Chang Gung Memorial Hospital and those who were stabilised initially at other hospitals in south-central Taiwan. METHODS: A retrospective review of the records of 254 patients with isolated severe TBI who visited this hospital's emergency department from July 2003 to June 2008, of whom 167 were referred from other hospitals. Logistic regression was used to assess the effects of transfer and its components on mortality. RESULTS: Transfer from another hospital was not significantly correlated with mortality in this study (OR 0.513, 95% CI 0.240 to 1.097). Moreover, neither intubation (OR 1.356, 95% CI 0.445 to 4.133) nor transfer time over 4 h (OR 0.549, 95% CI 0.119 to 1.744) had a significant effect on mortality. CONCLUSION: No differences in outcome were found between patients with isolated severe TBI who were directly transported and those transferred to this hospital's emergency room.

Acute and chronically increased immunoreactivity to phosphorylation-independent but not pathological TDP-43 after a single traumatic brain injury in humans.

The pathologic phosphorylation and sub-cellular translocation of neuronal transactive response-DNA binding protein (TDP-43) was identified as the major disease protein in frontotemporal lobar degeneration (FTLD) with ubiquitinated inclusions, now termed FTLD-TDP, and amyotrophic lateral sclerosis (ALS). More recently, TDP-43 proteinopathy has been reported in dementia pugilistica or chronic traumatic encephalopathy caused by repetitive traumatic brain injury (TBI). While a single TBI has been linked to the development of Alzheimer's disease and an increased frequency of neurofibrillary tangles, TDP-43 proteinopathy has not been examined with survival following a single TBI. Using immunohistochemistry specific for both pathological phosphorylated TDP-43 (p-TDP-43) and phosphorylation-independent TDP-43 (pi-TDP-43), we examined acute (n = 23: Survival < 2 weeks) and long-term (n = 39; 1-47 years survival) survivors of a single TBI versus age-matched controls (n = 47). Multiple regions were examined including the hippocampus, medial temporal lobe, cingulate gyrus, superior frontal gyrus and brainstem. No association was found between a history of single TBI and abnormally phosphorylated TDP-43 (p-TDP-43) inclusions. Specifically, just 3 of 62 TBI cases displayed p-TDP-43 pathology versus 2 of 47 control cases. However, while aggregates of p-TDP-43 were not increased acutely or long-term following TBI, immunoreactivity to phosphorylation-independent TDP-43 was commonly increased in the cytoplasm following TBI with both acute and long-term survival. Moreover, while single TBI can induce multiple long-term neurodegenerative changes, the absence of TDP-43 proteinopathy may indicate a fundamental difference in the processes induced following single TBI from those of repetitive TBI.

The epidemiology and impact of traumatic brain injury: a brief overview.

Traumatic brain injury (TBI) is an important public health problem in the United States and worldwide. The estimated 5.3 million Americans living with TBI-related disability face numerous challenges in their efforts to return to a full and productive life. This article presents an overview of the epidemiology and impact of TBI.

Prevalence and prognosis of traumatic intraventricular hemorrhage in patients with blunt head trauma.

BACKGROUND: Most studies of traumatic intraventricular hemorrhage (tIVH) contain fewer than 25 subjects and are retrospective in design, providing minimal information about the entity and its clinical significance. METHODS: We prospectively enrolled trauma patients from 18 centers in North America in the National Emergency X-Radiography Utilization Study (NEXUS) II if they received an emergent head computed tomography (CT) scan, as determined by the managing physician. Clinical data were collected at the time of enrollment and CT reports were compiled at least 1 month later. We calculated prevalence and demographics of tIVH from the 18 sites, while outcome data were gathered from medical records of patients with tIVH who were seen at any of six sites that participated in the follow-up portion of the study. We considered patients who underwent a neurosurgical intervention or who had a "poor outcome" (Glasgow Outcome Scale score of 1 to 3, death, persistent vegetative state, or severe disability) to have suffered a "combined outcome." RESULTS: Prevalence of tIVH among all trauma patients who received a head CT was 118 in 8,374, or 1.41%. Among tIVH patients, 70% had a "poor outcome" and 76% had a "combined outcome." A poor outcome appeared to be associated with an abnormal presenting Glasgow Coma Scale score and involvement of the third or fourth ventricle, whereas age appeared to be unrelated. Patients with tIVH and no major associated injury on CT tended to do well; only one patient with isolated tIVH had a poor outcome. CONCLUSIONS: Traumatic IVH is rare and is associated with poor outcomes that seem to be the consequence of associated injuries. Isolated tIVH patients who are clinically well appear to have a functional outcome; we were unable to identify a case of isolated tIVH, combined with a normal neurologic examination, resulting in a poor or combined outcome.

Disability in young people and adults after head injury: 5-7 year follow up of a prospective cohort study.

BACKGROUND: Improvement 1-2 years after head injury is well established but the pattern thereafter is unclear. Past studies have not examined representative head injury populations and typically report findings in terms of functioning across social, psychological, neurobehavioural, or cognitive domains rather than global outcome. OBJECTIVE: To determine the late outcome of a representative cohort of participants admitted to hospital after a head injury 5-7 years previously and to identify early and late factors correlating with persisting disability and change between one and 5-7 years. METHODS: A representative cohort of head injured people whose outcome one year after injury was reported previously, were followed up 5-7 years after injury. Participants were assessed using structured and validated measures of global outcome (Glasgow Outcome Scale Extended), cognitive impairment, psychological wellbeing, health status, and social factors. RESULTS: Of 475 survivors studied at one year, 115 (24%) had died by seven years. In survivors at 5-7 years, disability remained frequent (53%); and the rate, similar to that found at one year (57%). Sixty three participants (29%) had improved but 55 (25%) deteriorated. The persistence of disability and its development after previous recovery each showed stronger associations with indices of depression, anxiety, and low self-esteem than with initial severity of injury or persisting cognitive impairment. CONCLUSIONS: Admission to hospital after head injury is followed 5-7 years later by disability in a high proportion of survivors. Persistence of disability and development of new disability are strongly associated with psychosocial factors that may be open to remediation, even late after injury.

Amplitude-integrated electroencephalography coupled with an early neurologic examination enhances prediction of term infants at risk for persistent encephalopathy.

OBJECTIVES: The objectives of this study were to determine, first, whether an early neurologic examination could predict a persistent abnormal neonatal neurologic state comparable to the amplitude-integrated electroencephalography (a-EEG) and, second, whether a combination of the 2 methods would further enhance early identification of high-risk infants. METHODS: Fifty term infants were enrolled prospectively when they had evidence of intrapartum distress, Apgar score

Civilian infratentorial gunshot injuries: outcome analysis of 26 patients.

BACKGROUND: Craniocerebral missile injuries have steadily increased to become the most common form of penetrating neurotrauma in our environment resulting in continued morbidity and neuropsychological sequelae. Civilian infratentorial gunshot injuries are uncommon but generally regarded as fatal injuries, with many patients dying before reaching hospital. METHODS: A retrospective analysis of 1,069 patients with civilian gunshot wounds (GSW), admitted to our unit over a 14-year period (1986-2000), identified 26 patients with infratentorial gunshot injuries (2.4%). A detailed analysis of these patients was carried out, which included demographic factors, clinical and anatomic correlation, computed tomography scans, surgical management, and outcome. RESULTS: All patients were male. The mean age was 26.5 +/- 11.5 years and the mean admission Glasgow Coma Score 11.8 +/- 2.7. Twenty-four of 26 patients required cerebrospinal fluid (CSF) diversion to control secondary hydrocephalus. The second commonest surgical procedure was posterior fossa decompression. Five of 26 patients died (19.2%). Severe morbidity was noted in 9 of 21 surviving patients (42.8%). Significant predictors: good outcome was associated with primary missile entry of the infratentorial compartment (p = 0.005), while patients with supratentorial to infratentorial missile trajectory were noted to have a poorer outcome (p = 0.041). Location of cerebellar injury (lateral or medial) and missile caliber had no significant influence on patient outcome. CONCLUSION: Early control of incipient or established hydrocephalus and aggressive surgical management where appropriate, with careful postoperative monitoring, is necessary for good outcome in patients with civilian infratentorial missile injuries.

Morbidity and management conference: an approach to quality improvement in brain injury rehabilitation.

BACKGROUND: Program Evaluation and Quality Improvement (QI) are an ongoing focus of all brain injury rehabilitation programs, but it is difficult to consistently include the entire rehabilitation team in QI activities and to focus on issues that cross the continuum of care. In addition, recent reports have provided a renewed emphasis on reduction of medical errors and improving the overall quality of care for individuals with chronic conditions. Rehabilitation Medicine has a long history of working as a coordinated multidisciplinary team caring for complex patients with chronic conditions and is in a position to be a leader in QI activities. DESIGN: We have modified the traditional Morbidity and Mortality conference to include a multidisciplinary case discussion to identify system issues with quality of care. SETTING: This is completed in a nonpunitive format that does not assign individual blame. CONCLUSION: This Rehabilitation Morbidity and Management Conference is an important addition to the QI activities of our program.