Exercise Intolerance After Mild Traumatic Brain Injury Occurs in All Subtypes in the Adult Population.

Thematically grouped symptom clusters are present during the acute timeline of post-mild traumatic brain injuries (mTBI), representing clinical profiles called subtypes. Exercise intolerance has not been evaluated within the subtype classifications and, because guidelines support early submaximal aerobic exercise, further knowledge is required in regard to the exercise capabilities among the concussion subtypes. This cross-sectional study (n = 78) aimed to characterize the presence of exercise intolerance within the clinical subtypes and to explore performance on the Buffalo Concussion Treadmill Test (BCTT) in the adult subacute (2-12 weeks post-injury) mTBI population. All participants were evaluated using the BCTT to determine exercise tolerance. We first used the Neurobehavioral Symptom Inventory (NSI) questionnaire to assign each participant a primary subtype(s). To further explore all five subtypes (headache, cognitive, vestibular, ocular motor, and mood), participants were assessed using a multitude of thematically grouped assessments including self-reported questionnaires, clinical tests of vestibular and ocular motor function, balance function, and computerized cognitive testing. Thirty-seven (47%) subjects were exercise tolerant and 41 (53%) were exercise intolerant. There was no difference in the distribution of primary subtypes between the exercise tolerant and exercise intolerant groups. In addition, no significant differences were found between the exercise tolerant and exercise intolerant groups on other thematically grouped subtype assessments. The exercise intolerant group had a significantly higher resting heart rate (HR), lower percentage of age-predicted maximum HR achieved, lower Borg Rate of Perceived Exertion (RPE), and could walk on the treadmill for less time (lower duration) compared with the exercise tolerant group. The current findings suggest that exercise intolerance is common and pervasive across all five mTBI subtypes. A comprehensive mTBI assessment should include evaluation for exercise intolerance regardless of the primary clustering of symptoms and across patient populations. Therefore, early referral to physical therapists, athletic trainers, or medical clinics that can perform the BCTT may be helpful to initiate appropriate exercise prescriptions for patients with mTBI.

Assessing the Effects of Mild Traumatic Brain Injury on Vestibular Home Exercise Performance with Wearable Sensors.

After a mild traumatic brain injury (mTBI), dizziness and balance problems are frequently reported, affecting individuals' daily lives and functioning. Vestibular rehabilitation is a standard treatment approach for addressing these issues, but its efficacy in this population remains inconclusive. A potential reason for suboptimal outcomes is the lack of objective monitoring of exercise performance, which is crucial for therapeutic success. This study utilized wearable inertial measurement units (IMUs) to quantify exercise performance in individuals with mTBI during home-based vestibular rehabilitation exercises. Seventy-three people with mTBI and fifty healthy controls were enrolled. Vestibular exercises were performed, and IMUs measured forehead and sternum velocities and range of motions. The mTBI group demonstrated a slower forehead peak angular velocity in all exercises, which may be a compensatory strategy to manage balance issues or symptom exacerbation. Additionally, the mTBI group exhibited a larger forehead range of motion during specific exercises, potentially linked to proprioceptive deficits. These findings emphasize the usefulness of utilizing IMUs to monitor the quality of home-based vestibular exercises for individuals with mTBI and the potential for IMUs improving rehabilitation outcomes.

Implementation and Adoption of Telerehabilitation for Treating Mild Traumatic Brain Injury.

BACKGROUND AND PURPOSE: Multimodal physical therapy for mild traumatic brain injury (mTBI) has been shown to improve recovery. Due to the coronavirus disease-2019 (COVID-19) pandemic, a clinical trial assessing the timing of multimodal intervention was adapted for telerehabilitation. This pilot study explored feasibility and adoption of an in-person rehabilitation program for subacute mTBI delivered through telerehabilitation. METHODS: Fifty-six in-person participants-9 males; mean (SD) age 34.3 (12.2); 67 (31) days post-injury-and 17 telerehabilitation participants-8 males; age 38.3 (12.7); 61 (37) days post-injury-with subacute mTBI (between 2 and 12 weeks from injury) were enrolled. Intervention included 8, 60-minute visits over 6 weeks and included subcategories that targeted cervical spine, cardiovascular, static balance, and dynamic balance impairments. Telerehabilitation was modified to be safely performed at home with minimal equipment. Outcome measures included feasibility (the number that withdrew from the study, session attendance, home exercise program adherence, adverse events, telerehabilitation satisfaction, and progression of exercises performed), and changes in mTBI symptoms pre- and post-rehabilitation were estimated with Hedges' g effect sizes. RESULTS: In-person and telerehabilitation had a similar study withdrawal rate (13% vs 12%), high session attendance (92% vs 97%), and no adverse events. The telerehabilitation group found the program easy to use (4.2/5), were satisfied with care (4.7/5), and thought it helped recovery (4.7/5). The telerehabilitation intervention was adapted by removing manual therapy and cardiovascular portions and decreasing dynamic balance exercises compared with the in-person group. The in-person group had a large effect size (-0.94) in decreases in symptoms following rehabilitation, while the telerehabilitation group had a moderate effect size (-0.73). DISCUSSION AND CONCLUSIONS: Telerehabilitation may be feasible for subacute mTBI. Limited ability to address cervical spine, cardiovascular, and dynamic balance domains along with underdosage of exercise progression may explain group differences in symptom resolution.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A392 ).

Exploring persistent complaints of imbalance after mTBI: Oculomotor, peripheral vestibular and central sensory integration function.

BACKGROUND: Little is known on the peripheral and central sensory contributions to persistent dizziness and imbalance following mild traumatic brain injury (mTBI). OBJECTIVE: To identify peripheral vestibular, central integrative, and oculomotor causes for chronic symptoms following mTBI. METHODS: Individuals with chronic mTBI symptoms and healthy controls (HC) completed a battery of oculomotor, peripheral vestibular and instrumented posturography evaluations and rated subjective symptoms on validated questionnaires. We defined abnormal oculomotor, peripheral vestibular, and central sensory integration for balance measures among mTBI participants as falling outside a 10-percentile cutoff determined from HC data. A X-squared test associated the proportion of normal and abnormal responses in each group. Partial Spearman's rank correlations evaluated the relationships between chronic symptoms and measures of oculomotor, peripheral vestibular, and central function for balance control. RESULTS: The mTBI group (n = 58) had more abnormal measures of central sensory integration for balance than the HC (n = 61) group (mTBI: 41% -61%; HC: 10%, p's < 0.001), but no differences on oculomotor and peripheral vestibular function (p > 0.113). Symptom severities were negatively correlated with central sensory integration for balance scores (p's < 0.048). CONCLUSIONS: Ongoing balance complaints in people with chronic mTBI are explained more by central sensory integration dysfunction rather than peripheral vestibular or oculomotor dysfunction.

Evolving Science to Inform Emerging Concussion Practices.

Purpose This article describes two concussion models built on the current state of science that help illustrate the complicated interactions among the multiple factors that drive concussion symptoms. Consideration of these models remind practitioners, including speech-language pathologists, to attend to factors that increase the risk of patients developing prolonged symptoms, as well as attend to symptoms that result from various interactions and may differentially respond to specific treatments. In particular, the models encourage personalized or precision medicine and the implementation of targeted, coordinated therapies.

The Sensor Technology and Rehabilitative Timing (START) Protocol: A Randomized Controlled Trial for the Rehabilitation of Mild Traumatic Brain Injury.

BACKGROUND: Clinical practice for rehabilitation after mild traumatic brain injury (mTBI) is variable, and guidance on when to initiate physical therapy is lacking. Wearable sensor technology may aid clinical assessment, performance monitoring, and exercise adherence, potentially improving rehabilitation outcomes during unsupervised home exercise programs. OBJECTIVE: The objectives of this study were to: (1) determine whether initiating rehabilitation earlier than typical will improve outcomes after mTBI, and (2) examine whether using wearable sensors during a home-exercise program will improve outcomes in participants with mTBI. DESIGN: This was a randomized controlled trial. SETTING: This study will take place within an academic hospital setting at Oregon Health & Science University and Veterans Affairs Portland Health Care System, and in the home environment. PARTICIPANTS: This study will include 160 individuals with mTBI. INTERVENTION: The early intervention group (n = 80) will receive one-on-one physical therapy 8 times over 6 weeks and complete daily home exercises. The standard care group (n = 80) will complete the same intervention after a 6- to 8-week wait period. One-half of each group will receive wearable sensors for therapist monitoring of patient adherence and quality of movements during their home exercise program. MEASUREMENTS: The primary outcome measure will be the Dizziness Handicap Inventory score. Secondary outcome measures will include symptomatology, static and dynamic postural control, central sensorimotor integration posturography, and vestibular-ocular-motor function. LIMITATIONS: Potential limitations include variable onset of care, a wide range of ages, possible low adherence and/or withdrawal from the study in the standard of care group, and low Dizziness Handicap Inventory scores effecting ceiling for change after rehabilitation. CONCLUSIONS: If initiating rehabilitation earlier improves primary and secondary outcomes post-mTBI, this could help shape current clinical care guidelines for rehabilitation. Additionally, using wearable sensors to monitor performance and adherence may improve home exercise outcomes.

Analysis of Free-Living Mobility in People with Mild Traumatic Brain Injury and Healthy Controls: Quality over Quantity.

Balance and mobility issues are common non-resolving symptoms following mild traumatic brain injury (mTBI). Current approaches for evaluating balance and mobility following an mTBI can be subjective and suboptimal as they may not be sensitive to subtle deficits, particularly in those with chronic mTBI. Wearable inertial measurement units (IMU) allow objective quantification of continuous mobility outcomes in natural free-living environments. This study aimed to explore free-living mobility (physical activity and turning) of healthy and chronic mild traumatic brain injury (mTBI) participants using a single IMU. Free-living mobility was examined in 23 healthy control (48.56 ± 23.07 years) and 29 symptomatic mTBI (40.2 ± 12.1 years) participants (average 419 days post-injury, persistent balance complaints) over 1 week, using a single IMU placed at the waist. Free-living mobility was characterized in terms of macro (physical activity volume, pattern and variability) and micro-level (discrete measures of turning) features. Macro-level outcomes showed those with chronic mTBI had similar quantities of mobility compared with controls. Micro-level outcomes within walking bouts showed that chronic mTBI participants had impaired quality of mobility. Specifically, people with chronic mTBI made larger turns, had longer turning durations, slower average and peak velocities (all p < 0.001), and greater turn variability compared with controls. Results highlighted that the quality rather than quantity of mobility differentiated chronic mTBI from controls. Our findings support the use of free-living IMU continuous monitoring to enhance understanding of specific chronic mTBI-related mobility deficits. Future work is required to develop an optimal battery of free-living measures across the mTBI spectrum to aid application within clinical practice.

Inertial Sensors Reveal Subtle Motor Deficits When Walking With Horizontal Head Turns After Concussion.

OBJECTIVE: To examine whether horizontal head turns while seated or while walking, when instrumented with inertial sensors, were sensitive to the acute effects of concussion and whether horizontal head turns had utility for concussion management. SETTING: Applied field setting, athletic training room. PARTICIPANTS: Twenty-four collegiate athletes with sports-related concussion and 25 healthy control athletes. DESIGN: Case-control; longitudinal. MAIN MEASURES: Peak head angular velocity and peak head angle (range of motion) when performing head turns toward an auditory cue while seated or walking. Gait speed when walking with and without head turns. RESULTS: Athletes with acute sports-related concussion turned their head slower than healthy control subjects initially (group ß = -49.47; SE = 16.33; P = .003) and gradually recovered to healthy control levels within 10 days postconcussion (group × time ß = 4.80; SE = 1.41; P < .001). Peak head velocity had fair diagnostic accuracy in differentiating subjects with acute concussion compared with controls (areas under the receiver operating characteristic curve [AUC] = 0.71-0.73). Peak head angle (P = .17) and gait speed (P = .64) were not different between groups and showed poor diagnostic utility (AUC = 0.57-0.62). CONCLUSION: Inertial sensors can improve traditional clinical assessments by quantifying subtle, nonobservable deficits in people following sports-related concussion.

The Dynamics of Concussion: Mapping Pathophysiology, Persistence, and Recovery With Causal-Loop Diagramming.

Despite increasing public awareness and a growing body of literature on the subject of concussion, or mild traumatic brain injury, an urgent need still exists for reliable diagnostic measures, clinical care guidelines, and effective treatments for the condition. Complexity and heterogeneity complicate research efforts and indicate the need for innovative approaches to synthesize current knowledge in order to improve clinical outcomes. Methods from the interdisciplinary field of systems science, including models of complex systems, have been increasingly applied to biomedical applications and show promise for generating insight for traumatic brain injury. The current study uses causal-loop diagramming to visualize relationships between factors influencing the pathophysiology and recovery trajectories of concussive injury, including persistence of symptoms and deficits. The primary output is a series of preliminary systems maps detailing feedback loops, intrinsic dynamics, exogenous drivers, and hubs across several scales, from micro-level cellular processes to social influences. Key system features, such as the role of specific restorative feedback processes and cross-scale connections, are examined and discussed in the context of recovery trajectories. This systems approach integrates research findings across disciplines and allows components to be considered in relation to larger system influences, which enables the identification of research gaps, supports classification efforts, and provides a framework for interdisciplinary collaboration and communication-all strides that would benefit diagnosis, prognosis, and treatment in the clinic.

Detecting gait abnormalities after concussion or mild traumatic brain injury: A systematic review of single-task, dual-task, and complex gait.

BACKGROUND: While a growing number of studies have investigated the effects of concussion or mild traumatic brain injury (mTBI) on gait, many studies use different experimental paradigms and outcome measures. The path for translating experimental studies for objective clinical assessments of gait is unclear. RESEARCH QUESTION: This review asked 2 questions: 1) is gait abnormal after concussion/mTBI, and 2) what gait paradigms (single-task, dual-task, complex gait) detect abnormalities after concussion. METHODS: Data sources included MEDLINE/PubMed, Scopus, Web of Science, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) accessed on March 14, 2017. Original research articles reporting gait outcomes in people with concussion or mTBI were included. Studies of moderate, severe, or unspecified TBI, and studies without a comparator were excluded. RESULTS: After screening 233 articles, 38 studies were included and assigned to one or more sections based on the protocol and reported outcomes. Twenty-six articles reported single-task simple gait outcomes, 24 reported dual-task simple gait outcomes, 21 reported single-task complex gait outcomes, and 10 reported dual-task complex gait outcomes. SIGNIFICANCE: Overall, this review provides evidence for two conclusions: 1) gait is abnormal acutely after concussion/mTBI but generally resolves over time; and 2) the inconsistency of findings, small sample sizes, and small number of studies examining homogenous measures at the same time-period post-concussion highlight the need for replication across independent populations and investigators. Future research should concentrate on dual-task and complex gait tasks, as they showed promise for detecting abnormal locomotor function outside of the acute timeframe. Additionally, studies should provide detailed demographic and clinical characteristics to enable more refined comparisons across studies.

Abnormal Turning and Its Association with Self-Reported Symptoms in Chronic Mild Traumatic Brain Injury.

Turning is common in daily activity and requires rapid, coordinated reorientation of the head, trunk, and pelvis toward the new direction of travel. Yet, turning gait has not been well explored in populations with mild traumatic brain injury (mTBI) who may alter their turning behavior according to self-perceived symptoms or motor dysfunction. The purpose of this study was to examine turning velocities and coordination in adults with chronic mTBI (>3 months post-injury and still reporting balance complaints) during a task simulating everyday ambulation. We hypothesized that individuals with chronic mTBI would reduce their angular velocity when turning and increase the variability of head-pelvis coordination compared with controls, and that the reduction in velocity and increased variability would be associated with their self-reported symptom score. Forty-two adults (14 chronic mTBI, 28 controls) completed the Neurobehavioral Symptom Inventory before walking 12 laps around a marked course containing two 45-degree turns, four 90-degree turns, and two 135-degree turns. Inertial sensors collected angular velocities of the head and pelvis. After adjusting for covariates, participants with chronic mTBI had significantly slower lap times and peak angular velocities of the pelvis (p < 0.01) compared with the control group. The peak velocity timing (PVT) between peak velocities of the head and pelvis, and the variability of that timing was significantly greater in participants with chronic mTBI (p < 0.01). Within the chronic mTBI group, somatosensory symptoms were associated with slower angular velocities of the head and pelvis (p = 0.03) and increased PVT variability (p < 0.01). The results suggest individuals with chronic mTBI with worse somatic symptoms have impaired head stabilization during turning in situations similar to everyday life. These results encourage future research on turning gait to examine the causal relationship between symptoms and daily locomotor function in adults with chronic mTBI.

Concussion As a Multi-Scale Complex System: An Interdisciplinary Synthesis of Current Knowledge.

Traumatic brain injury (TBI) has been called "the most complicated disease of the most complex organ of the body" and is an increasingly high-profile public health issue. Many patients report long-term impairments following even "mild" injuries, but reliable criteria for diagnosis and prognosis are lacking. Every clinical trial for TBI treatment to date has failed to demonstrate reliable and safe improvement in outcomes, and the existing body of literature is insufficient to support the creation of a new classification system. Concussion, or mild TBI, is a highly heterogeneous phenomenon, and numerous factors interact dynamically to influence an individual's recovery trajectory. Many of the obstacles faced in research and clinical practice related to TBI and concussion, including observed heterogeneity, arguably stem from the complexity of the condition itself. To improve understanding of this complexity, we review the current state of research through the lens provided by the interdisciplinary field of systems science, which has been increasingly applied to biomedical issues. The review was conducted iteratively, through multiple phases of literature review, expert interviews, and systems diagramming and represents the first phase in an effort to develop systems models of concussion. The primary focus of this work was to examine concepts and ways of thinking about concussion that currently impede research design and block advancements in care of TBI. Results are presented in the form of a multi-scale conceptual framework intended to synthesize knowledge across disciplines, improve research design, and provide a broader, multi-scale model for understanding concussion pathophysiology, classification, and treatment.

Assessment and rehabilitation of central sensory impairments for balance in mTBI using auditory biofeedback: a randomized clinical trial.

BACKGROUND: Complaints of imbalance are common non-resolving signs in individuals with post-concussive syndrome. Yet, there is no consensus rehabilitation for non-resolving balance complaints following mild traumatic brain injury (mTBI). The heterogeneity of balance deficits and varied rates of recovery suggest varied etiologies and a need for interventions that address the underlying causes of poor balance function. Our central hypothesis is that most chronic balance deficits after mTBI result from impairments in central sensorimotor integration that may be helped by rehabilitation. Two studies are described to 1) characterize balance deficits in people with mTBI who have chronic, non-resolving balance deficits compared to healthy control subjects, and 2) determine the efficacy of an augmented vestibular rehabilitation program using auditory biofeedback to improve central sensorimotor integration, static and dynamic balance, and functional activity in patients with chronic mTBI. METHODS: Two studies are described. Study 1 is a cross-sectional study to take place jointly at Oregon Health and Science University and the VA Portland Health Care System. The study participants will be individuals with non-resolving complaints of balance following mTBI and age- and gender-matched controls who meet all inclusion criteria. The primary outcome will be measures of central sensorimotor integration derived from a novel central sensorimotor integration test. Study 2 is a randomized controlled intervention to take place at Oregon Health & Science University. In this study, participants from Study 1 with mTBI and abnormal central sensorimotor integration will be randomized into two rehabilitation interventions. The interventions will be 6 weeks of vestibular rehabilitation 1) with or 2) without the use of an auditory biofeedback device. The primary outcome measure is the daily activity of the participants measured using an inertial sensor. DISCUSSION: The results of these two studies will improve our understanding of the nature of balance deficits in people with mTBI by providing quantitative metrics of central sensorimotor integration, balance, and vestibular and ocular motor function. Study 2 will examine the potential for augmented rehabilitation interventions to improve central sensorimotor integration. TRIAL REGISTRATION: This trial is registered at clinicaltrials.gov ( NCT02748109 ).

The effectiveness of a web-based resource in improving postconcussion management in high schools.

PURPOSE: Because many sports concussions happen during school-sponsored sports events, most state concussion laws specifically hold schools accountable for coach training and effective concussion management practices. Brain 101: The Concussion Playbook is a Web-based intervention that includes training in sports concussion for each member of the school community, presents guidelines on creating a concussion management team, and includes strategies for supporting students in the classroom. METHODS: The group randomized controlled trial examined the efficacy of Brain 101 in managing sports concussion. Participating high schools (N = 25) were randomly assigned to the Brain 101 intervention or control. Fall athletes and their parents completed online training, and Brain 101 school administrators were directed to create concussion management policy and procedures. RESULTS: Student athletes and parents at Brain 101 schools significantly outperformed those at control schools on sports concussion knowledge, knowledge application, and behavioral intention to implement effective concussion management practices. Students who had concussions in Brain 101 schools received more varied academic accommodations than students in control schools. CONCLUSIONS: Brain 101 can help schools create a comprehensive schoolwide concussion management program. It requires minimal expenditures and offers engaging and effective education for teachers, coaches, parents, and students.

Concurrent little leaguer's elbow and shoulder in a 15-year-old baseball pitcher and football quarterback.

Little leaguer's elbow and Little leaguer's shoulder are overuse pathologies seen in overhead-throwing athletes. No instance of simultaneously occurring pathologies has been published. A 15-year-old baseball pitcher and football quarterback developed pain in his throwing shoulder and elbow during spring baseball, which partially resolved with several months of rest. During fall football practice, he felt a pop and pain over his medial throwing elbow. Five days after the initial injury, medial elbow tenderness, mild swelling, and decreased range of motion were noted. Radiographs revealed a Salter I avulsion fracture of the medial humeral epicondyle (Little leaguer's elbow) and a periosteal reaction along the lateral aspect of the humeral metadiaphysis with slight widening (Little leaguer's shoulder). Surgical fixation of the medial epicondyle fracture and nonoperative treatment of the shoulder pathology were performed. Two-year follow-up radiographs showed a healed medial epicondylar fracture and resolution of the periosteal reaction of the humeral metadiaphysis. The patient returned to full activity and was starting quarterback for his football team. Biomechanical forces specific to overhead-throwing activities are associated with the development of Little leaguer's elbow and shoulder. Treatments of both pathologies remain controversial, with either initial operative vs nonoperative care. In this patient, a good outcome was achieved with surgical fixation of the elbow fracture and conservative management of the shoulder pathology. Educating coaches and parents on proper throwing technique and pitching limits should be the first step in reducing the occurrence of either pathology in this population.

Efficacy of tart cherry juice in reducing muscle pain during running: a randomized controlled trial.

BACKGROUND: Long distance running causes acute muscle damage resulting in inflammation and decreased force production. Endurance athletes use NSAIDs during competition to prevent or reduce pain, which carries the risk of adverse effects. Tart cherries, rich in antioxidant and anti-inflammatory properties, may have a protective effect to reduce muscle damage and pain during strenuous exercise. This study aimed to assess the effects of tart cherry juice as compared to a placebo cherry drink on pain among runners in a long distance relay race. METHODS: The design was a randomized, double blind, placebo controlled trial. Fifty-four healthy runners (36 male, 18 female; 35.8 +/- 9.6 yrs) ran an average of 26.3 +/- 2.5 km over a 24 hour period. Participants ingested 355 mL bottles of tart cherry juice or placebo cherry drink twice daily for 7 days prior to the event and on the day of the race. Participants assessed level of pain on a standard 100 mm Visual Analog Scale (VAS) at baseline, before the race, and after the race. RESULTS: While both groups reported increased pain after the race, the cherry juice group reported a significantly smaller increase in pain (12 +/- 18 mm) compared to the placebo group (37 +/- 20 mm) (p < .001). Participants in the cherry juice group were more willing to use the drink in the future (p < 0.001) and reported higher satisfaction with the pain reduction they attributed to the drink (p < 0.001). CONCLUSIONS: Ingesting tart cherry juice for 7 days prior to and during a strenuous running event can minimize post-run muscle pain.