Age Suppresses the Association Between Traumatic Brain Injury Severity and Functional Outcomes: A Study Using the NIDILRR TBIMS Dataset.

OBJECTIVES: Recovery from traumatic brain injury (TBI) is extremely difficult to predict, with TBI severity usually demonstrating weak predictive validity for functional or other outcomes. A possible explanation may lie in the statistical phenomenon called suppression, according to which a third variable masks the true association between predictor and outcome, making it appear weaker than it actually is. Age at injury is a strong candidate as a suppressor because of its well-established main and moderating effects on TBI outcomes. We tested age at injury as a possible suppressor in the predictive chain of effects between TBI severity and functional disability, up to 10 years post-TBI. SETTING: Follow-up interviews were conducted during telephone interviews. PARTICIPANTS: We used data from the 2020 NDILRR Model Systems National Dataset for 4 successive follow-up interviews: year 1 (n = 10,734), year 2 (n = 9174), year 5 (n = 6,201), and year 10 (n = 3027). DESIGN: Successive cross-sectional multiple regression analyses. MAIN MEASURES: Injury severity was operationalized using a categorical variable representing duration of posttrauma amnesia. The Glasgow Outcomes Scale-Extended (GOS-E) operationally defined functioning. Sociodemographic characteristics having significant bivariate correlations with GOS-E were included. RESULTS: Entry of age at injury into the regression models significantly increases the association between TBI severity and functioning up to 10 years post-TBI. CONCLUSIONS: Age at injury is a suppressor variable, masking the true effect of injury severity on functional outcomes. Identifying the mediators of this suppression effect is an important direction for TBI rehabilitation research.

Evaluation of Low-Intensity Pulsed Ultrasound on Stress Fractures to Reduce the Time to Return to Sport or Activity in the Physically Active Population: A Systematic Review.

Stress fractures are a common and significant source of pain and burden that can require long periods of rest from physical activity to allow adequate healing. Specifically in athletes or those with physically demanding occupations, the prolonged period of rest and the potential for requiring surgical intervention in the case of poor or delayed healing can have devastating impacts on these individuals' careers and socioeconomic well-being. In this population, successful healing, in addition to a quicker healing time and a sooner return to activity, are important outcomes when faced with treating stress fractures. The use of low-intensity pulsed ultrasound (LIPUS) to accelerate bone healing has been a topic of investigation, though little research has explored the use of LIPUS specifically in the physically active population. The purpose of this study was to review the existing literature on the use of LIPUS for stress fracture healing in the physically active population with the outcome of a quicker return to sport or physical duties. The PubMed and Embase databases were screened for relevant articles using defined Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. Two independent researchers screened articles using PICOS criteria for inclusion in the review. Data were independently extracted regarding study and population characteristics as well as outcome measures, including time to healing of fractures and time to return to sport or physical activity. Five studies were ultimately included in the systematic review. One study investigated the use of LIPUS in pediatric athletes with spondylolysis, while four studies investigated lower extremity stress fractures in adult populations. All reported the outcomes of either rate or time to healing and ability to return to sport or activity. One study found a statistically significant improvement in the rate of bone union in the intervention group undergoing LIPUS compared to the control. Two studies found a statistically significant decrease in the time to resolution of symptoms, allowing an earlier return to sport or physical duties. Two studies found no difference in the time to healing or success rate of healing between the LIPUS group and the control group. This review of the literature suggests that the use of LIPUS for the treatment of stress fractures in the athletic or physically active population has the potential to expedite the resolution of symptoms and return to activity. Due to the heterogeneity of the existing studies, more research is needed to definitively determine the most appropriate clinical application of LIPUS and its most effective ultrasound settings. Further research should be directed toward more controlled studies specifically investigating the athletic and physically active population.

Platelet-Rich Plasma for Adhesive Capsulitis: A Systematic Review.

Adhesive capsulitis (AC) is a common cause of shoulder pain seen in 3%-5% of the population. Platelet-rich plasma (PRP) is platelet-rich blood with pro-inflammatory and anti-inflammatory properties that has been proposed as a treatment option for patients with AC. The purpose of this study was to analyze outcomes of range of motion (ROM) and subjective outcomes, including the visual analog scale (VAS), disability of arm, shoulder, and hand (DASH), and shoulder pain and disability index (SPADI) scores. PubMed, Embase, and Cochrane databases were searched, and manuscripts were screened using defined preferred reporting items for systematic reviews and meta-analyses (PRISMA) criteria. Two reviewers independently screened articles for inclusion/exclusion using PICOS criteria and extracted data regarding ROM and subjective outcome scores. Nineteen total articles were included. Eleven of the 19 studies recorded ROM as a dependent variable. All articles reported improved ROM with PRP injection when compared to baseline. When recording degrees of shoulder ROM in different planes at the latest follow-up, there were a total of 67 comparative data points for PRP vs. control. Of the 67 comparisons, 62 (93%) had a larger final ROM in the PRP group. VAS scores were reported in 16 of the 19 studies, DASH scores were reported in eight of the 19 articles, and SPADI scores were reported in seven of the 19 articles. VAS, DASH, and SPADI scores were all superior in the PRP group compared to the control. Two studies reported the same final VAS score, but the PRP groups had a larger overall improvement. Of the studies that reported objective ROM outcomes, the PRP group had greater ROM at the longest follow-up compared to control in the vast majority of comparisons. For the studies that reported subjective outcomes, all patients that received PRP had a decrease in VAS pain scores and an improvement in DASH and SPADI questionnaires.

Brain Injury: How Dietary Patterns Impact Long-Term Outcomes.

Purpose of Review: Individuals with a history of traumatic brain injury (TBI) are at a much greater risk for developing cardiovascular disease (CVD) compared to the general population. This review discusses dietary patterns as a means of addressing modifiable risk factors following TBI exposure. Evidence-based resources for practicing Physiatrists and Brain Injury Medicine specialists pertaining to nutrition education and counseling are also provided. Recent Findings: We examined Mediterranean, Dietary Approaches to Stop Hypertension, plant-based, ketogenic, and intermittent fasting dietary patterns through publications of clinical trials and systematic reviews. While many reviews had significant positive findings, some were limited by generalizability. Summary: While there is extensive literature on the immediate nutrition goals in the inpatient setting following an acute TBI exposure, there is limited literature discussing the nature of diet and nutrition in the post-acute setting. Fortunately, most individuals with TBI exposure survive their initial injury and continue into the recovery phase. The scientific literature supports increased morbidity and mortality with chronic TBI exposure compared to matched counterparts, most notably with CVD. A diet rich in fiber and nutrients but limited in added sugars, saturated fats, and excess calories would likely have the greatest cardiovascular and related neurologic protection. Future studies are needed to assess the specific impact of dietary interventions in the chronic phase of brain injury recovery.

Persistence of Hyper-Ramified Microglia in Porcine Cortical Gray Matter after Mild Traumatic Brain Injury.

Traumatic brain injury (TBI) is a major contributor to morbidity and mortality in the United States as several million people visit the emergency department every year due to TBI exposures. Unfortunately, there is still no consensus on the pathology underlying mild TBI, the most common severity sub-type of TBI. Previous preclinical and post-mortem human studies have detailed the presence of diffuse axonal injury following TBI, suggesting that white matter pathology is the predominant pathology of diffuse brain injury. However, the inertial loading produced by TBI results in strain fields in both gray and white matter. In order to further characterize gray matter pathology in mild TBI, our lab used a pig model (n = 25) of closed-head rotational acceleration-induced TBI to evaluate blood-brain barrier disruptions, neurodegeneration, astrogliosis, and microglial reactivity in the cerebral cortex out to 1 year post-injury. Immunohistochemical staining revealed the presence of a hyper-ramified microglial phenotype-more branches, junctions, endpoints, and longer summed process length-at 30 days post injury (DPI) out to 1 year post injury in the cingulate gyrus (p < 0.05), and at acute and subacute timepoints in the inferior temporal gyrus (p < 0.05). Interestingly, we did not find neuronal loss or astroglial reactivity paired with these chronic microglia changes. However, we observed an increase in fibrinogen reactivity-a measure of blood-brain barrier disruption-predominately in the gray matter at 3 DPI (p = 0.0003) which resolved to sham levels by 7 DPI out to chronic timepoints. Future studies should employ gene expression assays, neuroimaging, and behavioral assays to elucidate the effects of these hyper-ramified microglia, particularly related to neuroplasticity and responses to potential subsequent insults. Further understanding of the brain's inflammatory activity after mild TBI will hopefully provide understanding of pathophysiology that translates to clinical treatment for TBI.

Hypopituitarism After Mild Traumatic Brain Injury: A Case Report.

Hypopituitarism is characterized by an underactive pituitary gland and may result in growth hormone deficiency, hypothyroidism, testosterone deficiency, and/or adrenal insufficiency. Traumatic brain injury (TBI) exposure is a known risk factor for hypopituitarism. However, patients with hypopituitarism secondary to TBI exposure may go undiagnosed because the signs and symptoms of hypopituitarism can be subtle. This case report describes a 40-year-old male US military veteran who endorsed fatigue, sexual dysfunction, and weight gain several years after experiencing multiple mild TBIs during his military service. He ultimately underwent a full neuroendocrine workup that revealed low testosterone in addition to previously diagnosed hypothyroidism with a resolution of symptoms after starting testosterone therapy.

Blood-Based Biomarkers in Traumatic Brain Injury: A Narrative Review With Implications for the Legal System.

Traumatic brain injury (TBI) is an increasingly recognized diagnosis with significant, and often costly, associated consequences. Yet, despite their increased recognition, TBIs remain underdiagnosed. This issue is especially prominent in the context of mild TBI (mTBI), where there often exists little to no objective evidence of brain injury. In recent years, considerable effort has been made to better define and interpret known objective markers of TBI, as well as identify and explore new ones. An area of particular interest has focused on research related to blood-based biomarkers of TBI. Advancements in our understanding of TBI-related biomarkers can make it possible to characterize the severity of TBI with greater accuracy, improve our understanding of staging within both the injury process and the recovery process, and help us develop quantifiable metrics representative of reversal and recovery from a brain injury following trauma. Proteomic and non-proteomic blood-based biomarkers are being studied extensively and have shown promise for these purposes. Developments in this realm have significant implications not only for clinical care but also for legislation, as well as civil and criminal litigation. Despite their substantial potential, most of these biomarkers are not yet ready for use within the clinical setting, and therefore, are not appropriate for use within the legal or policy-making systems at this time. Given that existing standardization for the accurate and reliable use of TBI biomarkers is currently insufficient for use within either the clinical or legal realms, such data can be vulnerable to misuse and can even result in the abuse of the legal system for unwarranted gain. Courts will need to carefully evaluate the information presented in their role as gatekeepers of the admissibility of scientific evidence within the legal process. Ultimately, the development of biomarkers should lead to improved clinical care following TBI exposure, coherent and informed laws surrounding TBI, and more accurate and just results in litigation surrounding TBI-related sequelae.

Subacute Combined Degeneration Masking Spinal Stenosis: A Case Report.

Subacute combined degeneration (SCD) from vitamin B12 deficiency and spinal stenosis from degenerative changes may present similarly with weakness, sensory disturbances, and ataxia but require different treatments. This case report describes a 74-year-old male with suspected SCD who was discharged to an inpatient rehabilitation facility (IRF), did not improve with B12 supplementation, and later developed signs of myelopathy and diffuse joint pain. He ultimately was found to have severe cervical stenosis and pseudogout that were treated with a laminectomy and colchicine, respectively. Following surgical intervention, he returned to the IRF, where he had considerable functional improvement and was safely discharged home. This report shows the importance of recognizing the two conditions, their overlap, and the contrast between Occam's razor and Hickam's dictum.

A Systematic Review of Testosterone Therapy in Men With Spinal Cord Injury or Traumatic Brain Injury.

Spinal cord injuries (SCI) and traumatic brain injuries (TBI) increase the risk of testosterone deficiency and result in adverse changes in body composition and poor functional outcomes. The current systematic review aims to provide insights into the use of testosterone therapy for treating men with SCI and TBI. The PubMed and EMBASE databases were systematically reviewed using appropriate terms, and resulting manuscripts were screened using defined Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. The patient population included male patients with SCI or TBI. Further inclusion criteria were: a) human participants 18 years of age or older; b) manuscript published in English; c) study included an intervention with exogenous testosterone; and d) articles published in peer-reviewed journals with full text available. Two reviewers independently extracted data regarding injury type, intervention, and outcomes. Following screening for inclusion/exclusion criteria, a total of 12 primary research studies conducted over the last 30 years were included. Men with SCI were investigated in 11 articles. The combination of testosterone patches and resistance training with functional electrical stimulation (FES) for 16 weeks in men with SCI and an average baseline testosterone level above the cutoff for testosterone deficiency increased muscle mass, strength, bone quality, and basal metabolic rate while testosterone patches without exercise for 16 weeks produced no significant changes in these parameters. Testosterone patches for 12 months in men with SCI and testosterone deficiency also increased lean tissue mass (LTM) and resting energy expenditure (REE). In one study, men with TBI and testosterone deficiency receiving testosterone gel for eight weeks showed a non-statistically significant greater absolute change in functional independence measure (FIM) and grip strength compared to a placebo group. Testosterone therapy with exercise may help improve muscle mass, bone health, strength, energy expenditure, and cardiac health in men with SCI without major side effects. It is difficult to draw conclusions regarding the effects of testosterone therapy in men with TBI based on the limited available evidence. Further investigation is warranted to explore the relationship between testosterone therapy and recovery after SCI and TBI.

Nutrition Education, Understanding, and Counseling Practices Among Physiatrists: A Survey Study.

INTRODUCTION:  Nutritional counseling is relevant to physiatry practice. However, physiatrists' nutrition knowledge base and their frequency of incorporating nutritional education into routine clinical encounters are currently unknown. The objective of this study was to assess physiatrists' nutrition education, nutrition knowledge, willingness to implement nutrition counseling in clinical practice, and perceived barriers to providing nutritional counseling to patients, using an online survey. The hypothesis was that few physiatrists offer dietary counseling to their patients on a routine basis and that barriers likely include time constraints in a typical office visit, lack of provider confidence in providing dietary recommendations, and lack of provider reimbursement. METHODS: This study was a cross-sectional online survey that was distributed via email to a convenience sample of 179 resident, fellow, and attending physiatrists associated with two major academic institutions. The survey consisted of 26 questions regarding demographics, nutrition counseling practices and attitudes, basic nutrition knowledge, and perceived barriers to providing nutrition counseling. RESULTS: Of 59 participants, 78% reported receiving education in nutrition and/or behavioral counseling in medical school. In contrast, 39% of participants did not feel adequately trained to discuss nutrition and diet-related issues with patients. Barriers to providing nutritional counseling were time constraints (83%), socioeconomic factors outside of patients' control preventing them from adhering to a healthier diet (76%), and not having enough nutrition knowledge to do so appropriately (62%). Respondents (86%) either agreed or strongly agreed that additional training in nutrition would allow them to provide better clinical care in the prevention of progressive cardiovascular and neurovascular disease. Further, respondents (85%) either agreed or strongly agreed that they would be interested in a web-based continuing medical education training in nutrition behavioral counseling and evidence-based dietary recommendations. CONCLUSIONS:  The findings refuted the hypothesis that few physiatrists in the sample offer dietary counseling to their patients on a routine basis. Results demonstrated that many of them acknowledge its relevance and would be interested in further education on the subject. Physiatrists also appear to have perceived barriers to offering nutritional counseling, but some of them varied by the amount of medical experience. Based on these findings, this study demonstrated that it would be worthwhile to develop such a continuing medical education activity with a focus on populations commonly treated by physiatrists.

Cerebral Microvascular Pathology Is a Common Endophenotype Between Traumatic Brain Injury, Cardiovascular Disease, and Dementia: A Hypothesis and Review.

Traumatic brain injury (TBI) exposure has been associated with an increased risk of age-related cognitive decline or dementia in multiple epidemiological studies. Current therapeutic interventions in the field of Brain Injury Medicine focus largely on episodic symptom management during the chronic phase of TBI recovery, rather than targeting specific underlying pathological processes. This approach may be especially problematic for secondary age-related cognitive decline or dementia following TBI exposure. Although there are likely multiple pathophysiological mechanisms involved, a growing body of literature demonstrates that cerebral microvascular pathology is a common endophenotype across the spectrum of TBI severity. Similarly, a combination of pre-clinical and clinical research over the past two decades has implicated cerebral microvascular pathology in the initiation and progression of multiple neurodegenerative diseases, including Alzheimer's disease and other dementias. We hypothesize that cerebral microvascular pathology is a common endophenotype between TBI, cardiovascular disease (CVD), and dementia, which can be targeted through modifiable cardiovascular risk factor reductions during the chronic phase of TBI recovery. We posit that our hypothesis is supported by the currently available scientific literature, as detailed in our review.

A Preliminary Report: The Hippocampus and Surrounding Temporal Cortex of Patients With Schizophrenia Have Impaired Blood-Brain Barrier.

Though hippocampal volume reduction is a pathological hallmark of schizophrenia, the molecular pathway(s) responsible for this degeneration remains unknown. Recent reports have suggested the potential role of impaired blood-brain barrier (BBB) function in schizophrenia pathogenesis. However, direct evidence demonstrating an impaired BBB function is missing. In this preliminary study, we used immunohistochemistry and serum immunoglobulin G (IgG) antibodies to investigate the state of BBB function in formalin-fixed postmortem samples from the hippocampus and surrounding temporal cortex of patients with schizophrenia (n = 25) and controls without schizophrenia (n = 27) matched for age, sex, and race. Since a functional BBB prevents the extravasation of IgGs, detection of IgGs in the parenchyma is used as direct evidence of BBB breakdown. We also developed a semi-quantitative approach to quantify the extent of IgG leak and therein BBB breach. Analysis of our immunohistochemistry data demonstrated a significantly higher incidence of IgG leak in patients with schizophrenia compared to controls. Further, BBB permeability was significantly higher in advanced-age patients with schizophrenia than both advanced-age controls and middle-aged patients with schizophrenia. Male patients with schizophrenia also demonstrated a significant increase in IgG permeability compared to control males. Interestingly, the extravasated IgGs also demonstrated selective immunoreactivity for neurons. Based on these observations, we suggest that BBB dysfunction and IgG autoantibodies could be two key missing pathoetiological links underwriting schizophrenia hippocampal damage.

Blood Biomarkers in Brain Injury Medicine.

Purpose of Review: This review seeks to explore blood-based biomarkers with the potential for clinical implementation. Recent Findings: Emerging non-proteomic biomarkers hold promise for more accurate diagnostic and prognostic capabilities, especially in the subacute to chronic phase of TBI recovery. Further, there is a growing understanding of the overlap between TBI-related and Dementia-related blood biomarkers. Summary: Given the significant heterogeneity inherent in the clinical diagnosis of Traumatic Brain Injury (TBI), there has been an exponential increase in TBI-related biomarker research over the past two decades. While TBI-related biomarker assessments include both cerebrospinal fluid analysis and advanced neuroimaging modalities, blood-based biomarkers hold the most promise to be non-invasive biomarkers widely available to Brain Injury Medicine clinicians in diverse practice settings. In this article, we review the most relevant blood biomarkers for the field of Brain Injury Medicine, including both proteomic and non-proteomic blood biomarkers, biomarkers of cerebral microvascular injury, and biomarkers that overlap between TBI and Dementia.

Neuroimaging Findings in US Government Personnel With Possible Exposure to Directional Phenomena in Havana, Cuba.

IMPORTANCE: United States government personnel experienced potential exposures to uncharacterized directional phenomena while serving in Havana, Cuba, from late 2016 through May 2018. The underlying neuroanatomical findings have not been described. OBJECTIVE: To examine potential differences in brain tissue volume, microstructure, and functional connectivity in government personnel compared with individuals not exposed to directional phenomena. DESIGN, SETTING, AND PARTICIPANTS: Forty government personnel (patients) who were potentially exposed and experienced neurological symptoms underwent evaluation at a US academic medical center from August 21, 2017, to June 8, 2018, including advanced structural and functional magnetic resonance imaging analytics. Findings were compared with imaging findings of 48 demographically similar healthy controls. EXPOSURES: Potential exposure to uncharacterized directional phenomena of unknown etiology, manifesting as pressure, vibration, or sound. MAIN OUTCOMES AND MEASURES: Potential imaging-based differences between patients and controls with regard to (1) white matter and gray matter total and regional brain volumes, (2) cerebellar tissue microstructure metrics (eg, mean diffusivity), and (3) functional connectivity in the visuospatial, auditory, and executive control subnetworks. RESULTS: Imaging studies were completed for 40 patients (mean age, 40.4 years; 23 [57.5%] men; imaging performed a median of 188 [range, 4-403] days after initial exposure) and 48 controls (mean age, 37.6 years; 33 [68.8%] men). Mean whole brain white matter volume was significantly smaller in patients compared with controls (patients: 542.22 cm3; controls: 569.61 cm3; difference, -27.39 [95% CI, -37.93 to -16.84] cm3; P < .001), with no significant difference in the whole brain gray matter volume (patients: 698.55 cm3; controls: 691.83 cm3; difference, 6.72 [95% CI, -4.83 to 18.27] cm3; P = .25). Among patients compared with controls, there were significantly greater ventral diencephalon and cerebellar gray matter volumes and significantly smaller frontal, occipital, and parietal lobe white matter volumes; significantly lower mean diffusivity in the inferior vermis of the cerebellum (patients: 7.71 × 10-4 mm2/s; controls: 8.98 × 10-4 mm2/s; difference, -1.27 × 10-4 [95% CI, -1.93 × 10-4 to -6.17 × 10-5] mm2/s; P < .001); and significantly lower mean functional connectivity in the auditory subnetwork (patients: 0.45; controls: 0.61; difference, -0.16 [95% CI, -0.26 to -0.05]; P = .003) and visuospatial subnetwork (patients: 0.30; controls: 0.40; difference, -0.10 [95% CI, -0.16 to -0.04]; P = .002) but not in the executive control subnetwork (patients: 0.24; controls: 0.25; difference: -0.016 [95% CI, -0.04 to 0.01]; P = .23). CONCLUSIONS AND RELEVANCE: Among US government personnel in Havana, Cuba, with potential exposure to directional phenomena, compared with healthy controls, advanced brain magnetic resonance imaging revealed significant differences in whole brain white matter volume, regional gray and white matter volumes, cerebellar tissue microstructural integrity, and functional connectivity in the auditory and visuospatial subnetworks but not in the executive control subnetwork. The clinical importance of these differences is uncertain and may require further study.

Neurological Manifestations Among US Government Personnel Reporting Directional Audible and Sensory Phenomena in Havana, Cuba.

Importance: From late 2016 through August 2017, US government personnel serving on diplomatic assignment in Havana, Cuba, reported neurological symptoms associated with exposure to auditory and sensory phenomena. Objective: To describe the neurological manifestations that followed exposure to an unknown energy source associated with auditory and sensory phenomena. Design, Setting, and Participants: Preliminary results from a retrospective case series of US government personnel in Havana, Cuba. Following reported exposure to auditory and sensory phenomena in their homes or hotel rooms, the individuals reported a similar constellation of neurological symptoms resembling brain injury. These individuals were referred to an academic brain injury center for multidisciplinary evaluation and treatment. Exposures: Report of experiencing audible and sensory phenomena emanating from a distinct direction (directional phenomena) associated with an undetermined source, while serving on US government assignments in Havana, Cuba, since 2016. Main Outcomes and Measures: Descriptions of the exposures and symptoms were obtained from medical record review of multidisciplinary clinical interviews and examinations. Additional objective assessments included clinical tests of vestibular (dynamic and static balance, vestibulo-ocular reflex testing, caloric testing), oculomotor (measurement of convergence, saccadic, and smooth pursuit eye movements), cognitive (comprehensive neuropsychological battery), and audiometric (pure tone and speech audiometry) functioning. Neuroimaging was also obtained. Results: Of 24 individuals with suspected exposure identified by the US Department of State, 21 completed multidisciplinary evaluation an average of 203 days after exposure. Persistent symptoms (>3 months after exposure) were reported by these individuals including cognitive (n = 17, 81%), balance (n = 15, 71%), visual (n = 18, 86%), and auditory (n = 15, 68%) dysfunction, sleep impairment (n = 18, 86%), and headaches (n = 16, 76%). Objective findings included cognitive (n = 16, 76%), vestibular (n = 17, 81%), and oculomotor (n = 15, 71%) abnormalities. Moderate to severe sensorineural hearing loss was identified in 3 individuals. Pharmacologic intervention was required for persistent sleep dysfunction (n = 15, 71%) and headache (n = 12, 57%). Fourteen individuals (67%) were held from work at the time of multidisciplinary evaluation. Of those, 7 began graduated return to work with restrictions in place, home exercise programs, and higher-level work-focused cognitive rehabilitation. Conclusions and Relevance: In this preliminary report of a retrospective case series, persistent cognitive, vestibular, and oculomotor dysfunction, as well as sleep impairment and headaches, were observed among US government personnel in Havana, Cuba, associated with reports of directional audible and/or sensory phenomena of unclear origin. These individuals appeared to have sustained injury to widespread brain networks without an associated history of head trauma.

Biotensegrity: a unifying theory of biological architecture with applications to osteopathic practice, education, and research--a review and analysis.

Since its inception, osteopathic medicine has sought to identify the mechanical causes of disease and to understand the body's structure-function relationship. Research conducted during the past 25 years has demonstrated that the architectural principles of tensegrity can be applied to biological organisms (termed biotensegrity) and that these principles can demonstrate the mechanical structure-function relationship at all size scales in the human body. Further, biotensegrity at the cellular level allows the cell to mechanically sense its environment and convert mechanical signals into biochemical changes. When applied to the principles of osteopathic medicine, biotensegrity provides a conceptual understanding of the hierarchical organization of the human body and explains the body's ability to adapt to change. Further, biotensegrity explains how mechanical forces applied during osteopathic manipulative treatment could lead to effects at the cellular level, providing a platform for future research on the mechanisms of action of osteopathic manipulative treatment.

Use of osteopathic manipulative treatment to manage compensated trendelenburg gait caused by sacroiliac somatic dysfunction.

Gait dysfunctions are commonly encountered in the primary care setting. Compensated Trendelenburg gait is a gait dysfunction that was originally described in patients with weakness of ipsilateral hip abduction. This condition is thought to result from neuronal injury or myopathy. No treatment modalities currently exist for compensated Trendelenburg gait. The authors present a case in which osteopathic manipulative treatment may have improved a Trendelenburg gait dysfunction in a man aged 65 years with multiple sclerosis. Evidence of this improvement was obtained with the GaitMat II system for measuring numerous gait parameters. Based on the results reported in the present case, the authors propose that compensated Trendelenburg gait may arise from somatic dysfunction and may be corrected by osteopathic manipulative treatment.

Concurrent CBF and CMRGlc changes during human brain activation by combined fMRI-PET scanning.

A novel approach for concurrent measurement of regional cerebral blood flow (CBF) and regional cerebral metabolic rate for glucose consumption (CMRGlc) in humans is proposed and validated in normal subjects during visual stimulation. 18F-labeled fluorodeoxyglucose was administered during the measurement of CBF by continuous arterial spin labeled magnetic resonance imaging (MRI). Subsequent positron emission tomographic (PET) scanning demonstrated the distribution of labeled deoxyglucose during the MRI acquisition. An excellent concordance between regional CBF and regional CMRGlc during visual stimulation was found, consistent with previously published PET findings. Although initially validated using a brief, non-quantitative protocol, this approach can provide quantitative CBF and CMRGlc, with a broad range of potential applications in functional physiology and pathophysiology.