Preliminary evaluation of a measure for reliable assessment of need for constant visual observation in adults with traumatic brain injury.

PRIMARY OBJECTIVE: To develop and provide initial validation of a measure for accurately determining the need for Constant Visual Observation (CVO) in patients with traumatic brain injury (TBI) admitted to inpatient rehabilitation. RESEARCH DESIGN: Rating scale development and evaluation through Rasch analysis and assessment of concurrent validity. METHODS AND PROCEDURES: One hundred and thirty-four individuals with moderate-severe TBI were studied in seven inpatient brain rehabilitation units associated with the National Institute for Disability, Independent Living and Rehabilitation Research (NIDILRR) TBI Model System. Participants were rated on the preliminary version of the CVO Needs Assessment scale (CVONA) and, by independent raters, on the Levels of Risk (LoR) and Supervision Rating Scale (SRS) at four time points during inpatient rehabilitation: admission, Days 2-3, Days 5-6 and Days 8-9. OUTCOMES AND RESULTS: After pruning misfitting items, the CVONA showed satisfactory internal consistency (Person Reliability = 0.85-0.88) across time points. With reference to the LoR and SRS, low false negative rates (sensitivity > 90%) were associated with moderate-to-high false positive rates (29-56%). CONCLUSIONS: The CVONA may be a useful objective metric to complement clinical judgement regarding the need for CVO; however, further prospective study is desirable to further assess its utility in identifying at-risk patients, reducing adverse events and decreasing CVO costs.

Efficacy of amantadine treatment on symptoms and neurocognitive performance among adolescents following sports-related concussion.

OBJECTIVE: To evaluate the efficacy of amantadine in the treatment of symptoms and neurocognitive performance in adolescents following sports-related concussion. PARTICIPANTS: A clinical sample of 25 male (n = 11) and female (n = 14) adolescent subjects with an age-, sex-, and concussion history-matched group of 25 male (n = 11) and female (n = 14) control subjects. SETTING: Outpatient concussion clinic. INTERVENTION: Retrospective, case-control design. Treatment group consisted of patients treated with 100 mg of amantadine twice daily (200 mg total per day) following a period of rest. Matched controls were evaluated and treated conservatively without medication at the same concussion program prior to the start of the current amantadine protocol. MAIN OUTCOME MEASURES: Immediate Postconcussion Assessment and Cognitive Test computerized neurocognitive test battery and symptom report. RESULTS: Results support significantly greater improvements from pre- to posttest in reported symptoms, verbal memory, and reaction time performance for the amantadine group than the matched controls. There were no significant differences for visual memory or visual motor processing speed. CONCLUSION: This study provides empirical support for amantadine as an effective pharmacologic treatment of certain concussion-related cognitive deficits and symptoms in athletes with protracted recovery of more than 3 weeks.

Concussion management and treatment considerations in the adolescent population.

Over the past decade, significant advances have been made in understanding concussions. Information regarding proper identification, pathophysiology, risks, outcomes, and management protocols has shifted the treatment paradigm from a generalized grading system to an individualized approach. Early identification and timely management of a concussion is necessary to ensure that patients minimize persistent post-concussive symptoms affecting the physical, behavioral, emotional, and cognitive domains. Adolescents are particularly vulnerable to concussions, having greater susceptibility and more prolonged recovery after sustaining an injury. This article aims to inform clinicians on how to improve symptom relief and functional outcomes for adolescent patients with concussion via immediate intervention, neuropsychological management, and pharmacological treatment.

Sports concussion: management and predictors of outcome.

Interest in sports concussion has grown widely in the last two decades among laypersons and medical professionals. Significant contributions of evidence-based research have led to a better understanding of this multifaceted, but still often elusive, injury. This information has transformed all aspects of concussion management, from on-field evaluation through return-to-play guidelines. The aim of this article is to highlight important research regarding predictors of outcome and treatment protocols. This research has been the basis of the paradigm shift from traditional concussion grading scales to individualized care. Today, concussion management requires a patient-centered approach with individualized assessment, including risk factor analysis, neurocognitive testing, and a thorough symptom evaluation.

Adolescent sports concussion.

Approximately 2 million sports and recreation concussive injuries occur per year in the United States, which may be an underestimate because of inconsistent data reporting. The field of concussion management has evolved rapidly over the last 10 years, and with these advances comes new understanding of the significant symptomatic and cognitive impairments of concussion. These sequelae are more fully realized and may last longer than previously thought. Data have emerged regarding pathophysiology of concussion, risk factors, outcome, effects of repetitive injury, subtypes of concussive injury, and treatment protocols. This evidence calls for more conservative management of concussion, particularly in younger athletes, and demonstrates the shortcomings of concussion guidelines.

Managing Patients with Prolonged Recovery Following Concussion.

Persistent symptoms following concussion can be debilitating for patients and challenging for clinicians; however, evidence-based approaches to symptom management are emerging. The presentation of postconcussion syndrome can be variable among patients. Given this variability, a thorough history and physical examination are necessary to tailor an individualized treatment approach. Pharmacologic interventions can be considered when prolonged symptoms are negatively affecting quality of life. This article reviews evidence available to guide such treatment decisions.

Stroke and neurodegenerative disorders: 2. Poststroke medical complications.

OBJECTIVE: This self-directed learning module highlights common poststroke medical complaints encountered on an inpatient rehabilitation unit. It is part of the study guide on stroke and neurodegenerative disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. Using a case vignette format, this article specifically focuses on the differential diagnosis, evaluation and management of chest pain, mental status changes, weight loss and poor motivation in stroke patients. The goal of this article is to expand the learner's knowledge of how to diagnose and manage common medical complications of stroke patients in rehabilitation.

Stroke and neurodegenerative disorders: 3. Poststroke rehabilitation.

OBJECTIVE: This self-directed learning module highlights rehabilitation strategies in poststroke rehabilitation. It is part of the study guide on stroke and neurodegenerative disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. Using a case vignette format, this article specifically focuses on typical clinical presentations, recovery patterns, and traditional and innovative therapeutic interventions in poststroke rehabilitation such as constraint-induced movement therapy, treadmill training, functional electrical stimulation, robot-aided therapy, virtual reality treatment, cortical stimulation, speech therapy for aphasia, and orthotic management. The goal of this article is to influence the learner's knowledge on the delivery of poststroke rehabilitation treatment.

Stroke and neurodegenerative disorders: 4. Community integration.

OBJECTIVE: This self-directed learning module highlights common rehabilitation issues in stroke survivors with chronic impairments with emphasis on community integration. It is part of the study guide on stroke and neurodegenerative disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. Using a case vignette format, this article specifically focuses on management of shoulder pain, management of hypertonia, secondary stroke prevention, vocational reintegration including strategies for return to driving, and treatment of sexual dysfunction following stroke. The goal of this article is to improve the learner's ability to implement community integration strategies after a stroke.

Stroke and neurodegenerative disorders: 1. Stroke management in the acute care setting.

OBJECTIVE: This self-directed learning module highlights management of stroke in the acute care setting. It is part of the study guide on stroke and neurodegenerative disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. Using a case vignette format, this article specifically focuses on initial assessment and management of acute ischemic and hemorrhagic stroke, descriptions of posterior circulation and lacunar stroke, and criteria for admission to acute inpatient rehabilitation after stroke and secondary stroke prevention. The goal of this article is to improve the learner's ability to identify, treat and manage a patient with a stroke in the acute care setting.

Rehabilitation interventions in Parkinson disease.

OBJECTIVE: This self-directed learning module provides an evidence-based update of exercise-based rehabilitation interventions to treat Parkinson disease (PD). It is part of the study guide on stroke and neurodegenerative disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This focused review emphasizes treatment of locomotion deficits, upper limb motor control deficits, and hypokinetic dysarthria. New dopaminergic agents and deep brain stimulation are facilitating longer periods of functional stability for patients with PD. Adjunctive exercise-based treatments can therefore be applied over longer periods of time to optimize function before inevitable decline from this neurodegenerative disease. As function deteriorates in patients with PD, the role of caregivers becomes more critical, thus training caregivers is of paramount importance to help maintain a safe environment and limit caregiver anxiety and depression. The overall goal of this article is to enhance the learner's existing practice techniques used to treat PD through exercise-based intervention methods.

Concussion in sports: postconcussive activity levels, symptoms, and neurocognitive performance.

CONTEXT: Evidence suggests that athletes engaging in high-intensity activities after concussion have more difficulties with cognitive recovery. OBJECTIVE: To examine the role postinjury activity level plays in postconcussive symptoms and performance on neurocognitive tests in a population of student-athletes. DESIGN: Retrospective cohort study with repeated measures of neurocognitive performance and symptom reporting. SETTING: University-based sports concussion clinic. PATIENTS OR OTHER PARTICIPANTS: Ninety-five student-athletes (80 males, 15 females: age = 15.88 +/- 1.35 years) were retrospectively assigned to 1 of 5 groups based on a postinjury activity intensity scale. MAIN OUTCOME MEASURE(S): We employed a regression analysis for repeated measures to evaluate the relationship of activity intensity to symptoms and neurocognitive outcome up to 33 days after concussion. Postconcussion symptom scores and neurocognitive (verbal memory, visual memory, visual motor speed, and reaction time) scores served as the primary outcome measures. RESULTS: Level of exertion was significantly related to all outcome variables (P < .02 for all comparisons). With multivariate analysis, activity intensity remained significant with respect to visual memory (P = .003) and reaction time (P < .001). CONCLUSIONS: Activity level after concussion affected symptoms and neurocognitive recovery. Athletes engaging in high levels of activity after concussion demonstrated worse neurocognitive performance. For these tasks, those engaging in moderate levels of activity demonstrated the best performance.