Experiences of Domestic Violence in Adult Patients with Brain Injury: A Select Overview of Screening, Reporting, and Next Steps.

This select overview examines the important intersection of adult domestic violence, including intimate partner violence and elder abuse, with brain injury. Despite the high prevalence of domestic violence amongst brain injury patients, there is a notable gap in screening and management training for providers. To provide optimal patient care, brain injury medicine clinicians must screen, recognize, and treat patients who have experienced domestic violence. This select overview highlights barriers to screening, validated screening tools from other medical disciplines, and management considerations for the brain injury clinician. A suggested protocol for domestic violence screening and management, as well as recommended resources for providers and patients, is summarized.

Community Reintegration After Traumatic Brain Injury.

Achieving effective community reintegration is important to maximize recovery in patients with traumatic brain injury, simultaneously limiting caregiver burden and improving satisfaction with quality of life. Certain medical complications that are common after brain injury may impact community reintegration, and should be addressed by the physician in a systematic approach. Additionally certain social and environmental factors such as mobility or return to work or school may arise, and should be addressed proactively by the physician. Inpatient/residential or outpatient programs with case management and a multi-disciplinary team can facilitate community reentry for patients, and should be considered when available.

Educating families of brain injury patients during acute rehabilitation: a quality improvement project.

ABSTRACT: Lack of information is cited as a source of distress for caregivers of patients with brain injury during the recovery process. This is a quality improvement project with the purpose of educating family members of brain injury patients about acute inpatient rehabilitation and providing a reliable source of information through the Model Systems Knowledge Translation Center (MSKTC) Traumatic Brain Injury Model Systems (TBIMS) Factsheets. The study was conducted in the brain injury unit of an acute inpatient rehabilitation facility and a total of n = 32 family members participated in the study. Educational sessions were provided verbally by phone based on the MSKTC-TBIMS "Traumatic Brain Injury and Acute Inpatient Rehabilitation" Factsheet. Surveys with five confidence statements and Likert scale graded responses were verbally administered by phone immediately before and after each educational session to evaluate for understanding. There was a statistically significant increase in confidence for all five confidence statements when comparing pre-and post-education responses (p < 0.05, Wilcoxon signed-rank test). This quality improvement project thereby presents an effective and feasible framework for teaching, improving communication, and providing valuable information to families early in the brain injury rehabilitation course.

Speech recovery after single-dose zolpidem in two minimally conscious patients with severe traumatic brain injuries: a case report.

BACKGROUND: In rare cases, zolpidem administration has been found to paradoxically improve cognition in patients with brain injury in disorders of consciousness. CASE PRESENTATION: Two minimally conscious plus (MCS+) patients at baseline, a 24-year-old woman 8 weeks post-traumatic brain injury (TBI) and 23-year-old man 6 weeks post-TBI, demonstrated behavioral improvements after off-label, single-dose administration of 10 mg of zolpidem. DISCUSSION/CONCLUSION: The patients demonstrated improved cognition on Coma Recovery Scale-Revised assessment after ingesting zolpidem. In particular, speech was substantially restored as one patient recovered functional communication and both demonstrated intelligible verbalizations for the first-time post-injuries following zolpidem. Overall, evidence is limited regarding the underlying mechanisms of various cognitive improvements in zolpidem response although studies incorporating neuroimaging are promising. The outcomes and similarities between these cases contribute to the current literature and highlight the need for rigorous studies in the future to guide zolpidem trials in patient care for those with DOC.

Update on How to Approach a Patient with Locked-In Syndrome and Their Communication Ability.

Locked-in syndrome (LIS) is a rare and challenging condition that results in tetraplegia and cranial nerve paralysis while maintaining consciousness and variable cognitive function. Once acute management is completed, it is important to work with the patient on developing a plan to maintain and improve their quality of life (QOL). A key component towards increasing or maintaining QOL within this population involves the establishment of a functional communication system. Evaluating cognition in patients with LIS is vital for evaluating patients' communication needs along with physical rehabilitation to maximize their QOL. In the past decade or so, there has been an increase in research surrounding brain-computer interfaces to improve communication abilities for paralyzed patients. This article provides an update on the available technology and the protocol for finding the best way for patients with this condition to communicate. This article aims to increase knowledge of how to enhance and manage communication among LIS patients.

Persistent facial nerve palsy after middle meningeal artery embolization for subdural hematoma: a case report.

OBJECTIVE: To describe a case of persistent facial nerve palsy after middle meningeal artery (MMA) embolization for chronic subdural hematoma (cSDH). METHODS: A literature search was conducted for publications within the last 10 years of facial nerve palsy following cerebral circulation embolization procedures. RESULTS: With inconsistencies between previously believed pathophysiology and clinical features, other mechanisms causing cSDH such as angiogenesis and capillary formation have been proposed. MMA embolization has evolved as a therapeutic approach to reduce recurrence of subdural hematoma; however, postoperative neural complications such as cranial nerve palsies are poorly described in the literature. CONCLUSIONS: cSDH is increasingly more common and is on trajectory to become the most prevalent cranial neurosurgical condition. MMA embolization is described as a safe and minimally invasive procedure; however, as a relatively new procedure further research is needed to elucidate associated complications.

Update on Non-Pharmacological Interventions for Treatment of Post-Traumatic Headache.

Post-traumatic headache (PTH) is the most common sequelae of traumatic brain injury (TBI). Its phenotypic variability, absence of formal evidence-based guidelines for treatment and underdiagnosis have made its management a challenge for clinicians. As a result, treatment of PTH has been mostly empiric. Although analgesics are the most popular drug of choice for PTH, they can present with several adverse effects and fail to address other psychosocial comorbidities associated with TBI. Non-pharmacological interventions thereby offer an intriguing alternative that can provide patients with PTH sustainable and effective care. This review article aims to: (1) provide an update on and describe different non-pharmacological interventions present in the recent literature; (2) provide clinical guidance to providers struggling with the management of patients with PTH; (3) emphasize the need for more high-quality trials examining the effectiveness of non-pharmacological treatments in patients with PTH. This review discusses 21 unique non-pharmacological treatments used for the management of PTH. Current knowledge of non-pharmacological interventions for the treatment of PTH is based on smaller scale studies, highlighting the need for larger randomized controlled trials to help establish formal evidence-based guidelines.

Update on Domestic Violence and Traumatic Brain Injury: A Narrative Review.

Research on traumatic brain injury (TBI) as a result of domestic violence has greatly increased in the past decade, with publications addressing the prevalence, diagnosis, evaluation, and treatment. Although TBI due to domestic violence has recently been found to occur quite frequently, it was not widely understood until the 1990s. Individuals who suffer from domestic violence TBI often experience sequelae such as decreased cognitive functioning, memory loss, and PTSD. The goal of this article is to increase awareness about TBI secondary to domestic violence, with the intent that it will highlight areas for future research on the diagnosis, evaluation, and treatment of TBI in this population. The articles in this study were first found using the search terms traumatic brain injury and domestic violence. Although, in recent years, there has been a significant increase in research on TBI due to domestic violence, the overall conclusion of this review article is that there is still a need for future research in many areas including the effects on minority populations, the effects of COVID-19, and improvements of screening tools.

The changing landscape of the use of medical marijuana after traumatic brain injury: a narrative review.

OBJECTIVE: To summarize the potential therapeutic benefits of medical marijuana for patients with traumatic brain injury (TBI). METHODS: A systematic search was conducted using PubMed and Cochran's library for information regard the safety and efficacy of medical marijuana as a therapeutic agent. We investigated, in depth, articles specifically evaluating medical marijuana's use in TBI, as well as articles that summarized the effects of marijuana in general. Articles from the year 2000-2020 were included. RESULTS: A total of 37 articles met our inclusion criteria. An additional 3 articles were obtained from reference lists. CONCLUSION: Studies have shown that medical marijuana can potentially aid the recovery from TBI by modulating the endocannabinoid system, reducing inflammation and secondary injury. Adverse cognitive and physiological effects have been observed in the acute setting as well as chronically, though more research is necessitated. There is also the concern of significant drug-drug interactions that have not been thoroughly studied. Thus, while there is evidence that medical marijuana can be beneficial in the treatment of TBI, more research is necessitated to fully explore the long-term efficacy and adverse effects.

Rehabilitation Outcomes in Subjects with West Nile Neuro-Invasive Disease.

West Nile Virus (WNV) is the most common mosquito borne cause of viral encephalitis in the United States. Physical and neuro-cognitive recovery from WNND may be prolonged or incomplete leading to chronic cognitive inefficiencies and functional decline. There continues to be no effective treatment of WNV and current management is primarily supportive. The objective of this review is to evaluate the functional outcomes and role of rehabilitation services in subjects with WNND. The charts of five subjects admitted to an acute inpatient brain injury rehabilitation facility from June to December 2012 were retrospectively reviewed. (Mean, Range)-Age (64.8, 43-78 years), Admission Functional Independence Measure (FIM) (45.2, 14-63), Discharge FIM (82.2, 61-100), FIM score gain (37, 24-60), Cognitive FIM gain (7, 1-18), Mobility FIM gain (17.4, 13-20), ADL FIM gain (12.6, 4-23); acute brain injury inpatient rehabilitation facility length of stay (LOS) (17.8, 14-21 days); acute hospital LOS (15, 10-22 days). Of the five subjects, three were discharged home, one was discharged to a skilled nursing facility, and one was discharged to an assisted living facility. Subjects with WNND have significant functional decline across all FIM subcategories and may benefit from a course of brain injury-specific acute inpatient rehabilitation.

Low Vitamin D Level Is Associated with Acute Deep Venous Thrombosis in Patients with Traumatic Brain Injury.

Vitamin D and its association with venous thromboembolism (VTE) have been studied in common rehabilitation populations, such as spinal cord injury and ischemic stroke groups. This study explores the relationship between vitamin D levels and acute deep venous thrombosis (DVT) in the traumatic brain injury (TBI) population. This is a retrospective cohort study that analyzes the relationship between vitamin D levels and the prevalence of DVT during acute inpatient rehabilitation. In this population, 62% (117/190) of patients had low vitamin D levels upon admission to acute rehabilitation. Furthermore, 21% (24/117) of patients in the low vitamin D group had acute DVT during admission to acute rehabilitation. In contrast, only 8% (6/73) of patients in the normal vitamin D group had acute DVT during admission to acute rehabilitation. Fisher's exact tests revealed significant differences between individuals with low and normal vitamin D levels (p = 0.025). In conclusion, a vitamin D level below 30 ng/mL was associated with increased probability of the occurrence of acute DVT in individuals with moderate-severe TBI.

Functional Change from Five to Fifteen Years after Traumatic Brain Injury.

Few studies have assessed the long-term functional outcomes of traumatic brain injury (TBI) in large, well-characterized samples. Using the Traumatic Brain Injury Model Systems cohort, this study assessed the maintenance of independence between years 5 and 15 post-injury and risk factors for decline. The study sample included 1381 persons with TBI who received inpatient rehabilitation, survived to 15 years post-injury, and were available for data collection at 5 or 10 years and 15 years post-injury. The Functional Independence Measure (FIM) and Disability Rating Scale (DRS) were used to measure functional outcomes. The majority of participants had no changes during the 10-year time frame. For FIM, only 4.4% showed decline in Self-Care, 4.9% declined in Mobility, and 5.9% declined in Cognition. Overall, 10.4% showed decline in one or more FIM subscales. Decline was detected by DRS Level of Function (24% with >1-point change) and Employability (6% with >1-point change). Predictors of decline factors across all measures were age >25 years and, across most measures, having less than or equal to a high school education. Additional predictors of FIM decline included male sex (FIM Mobility and Self-Care) and longer rehabilitation length of stay (FIM Mobility and Cognition). In contrast to studies reporting change in the first 5 years post-TBI inpatient rehabilitation, a majority of those who survive to 15 years do not experience functional decline. Aging and cognitive reserve appear to be more important drivers of loss of function than original severity of the injury. Interventions to identify those at risk for decline may be needed to maintain or enhance functional status as persons age with a TBI.

Deaf intermarriage has limited effect on the prevalence of recessive deafness and no effect on underlying allelic frequency.

The idea that deaf intermarriage increases the prevalence of deafness was forcefully pushed in the late 19th century by Alexander Graham Bell, in proceedings published by the National Academy of Science. Bell's hypothesis was not supported by a 19th century study by Edward Allen Fay, which was funded by Bell's own organization, the Volta Bureau. The Fay study showed through an analysis of 4,471 deaf marriages that the chances of having deaf children did not increase significantly when both parents were deaf. In light of an apparent increase in non-complementary pairings when a modern dataset of Gallaudet alumni was compared with the 19th century Fay dataset, Bell's argument has been resurrected. This hypothesis is that residential schools for the deaf, which concentrate signing deaf individuals together, have promoted assortative mating, which in turn has increased the prevalence of recessive deafness and also the commonest underlying deafness allele. Because this hypothesis persists, even though it contradicts classical models of assortative mating, it is critically important that it be thoroughly investigated. In this study, we used an established forward-time genetics simulator with parameters and measurements collected from the published literature. Compared to mathematical equations, simulations allowed for more complex modeling, operated without assumptions of parametricity, and captured ending distributions and variances. Our simulation results affirm predictions from classical equations and show that intense assortative mating only modestly increases the prevalence of deafness, with this effect mostly completed by the third generation. More importantly, our data show that even intense assortative mating does not affect the frequency of the underlying alleles under reported conditions. These results are not locus-specific and are generalizable to other forms of recessive deafness. We explain the higher rate of non-complementary pairings measured in the contemporary Gallaudet alumni sample as compared to the Fay dataset.

Rehabilitation of Adult Patients with Primary Brain Tumors: A Narrative Review.

Rehabilitative measures have been shown to benefit patients with primary brain tumors (PBT). To provide a high quality of care, clinicians should be aware of common challenges in this population including a variety of medical complications, symptoms, and impairments, such as headaches, seizures, cognitive deficits, fatigue, and mood changes. By taking communication and family training into consideration, clinicians can provide integrated and patient-centered care to this population. This article looks to review the current literature in outpatient and inpatient rehabilitation options for adult patients with PBTs as well as explore the role of the interdisciplinary team in providing survivorship care.

Post-traumatic Confusional State: A Case Definition and Diagnostic Criteria.

In response to the need to better define the natural history of emerging consciousness after traumatic brain injury and to better describe the characteristics of the condition commonly labeled posttraumatic amnesia, a case definition and diagnostic criteria for the posttraumatic confusional state (PTCS) were developed. This project was completed by the Confusion Workgroup of the American Congress of Rehabilitation Medicine Brain Injury Interdisciplinary Special Interest group. The case definition was informed by an exhaustive literature review and expert opinion of workgroup members from multiple disciplines. The workgroup reviewed 2466 abstracts and extracted evidence from 44 articles. Consensus was reached through teleconferences, face-to-face meetings, and 3 rounds of modified Delphi voting. The case definition provides detailed description of PTCS (1) core neurobehavioral features, (2) associated neurobehavioral features, (3) functional implications, (4) exclusion criteria, (5) lower boundary, and (6) criteria for emergence. Core neurobehavioral features include disturbances of attention, orientation, and memory as well as excessive fluctuation. Associated neurobehavioral features include emotional and behavioral disturbances, sleep-wake cycle disturbance, delusions, perceptual disturbances, and confabulation. The lower boundary distinguishes PTCS from the minimally conscious state, while upper boundary is marked by significant improvement in the 4 core and 5 associated features. Key research goals are establishment of cutoffs on assessment instruments and determination of levels of behavioral function that distinguish persons in PTCS from those who have emerged to the period of continued recovery.

Minimum Competency Recommendations for Programs That Provide Rehabilitation Services for Persons With Disorders of Consciousness: A Position Statement of the American Congress of Rehabilitation Medicine and the National Institute on Disability, Independent Living and Rehabilitation Research Traumatic Brain Injury Model Systems.

Persons who have disorders of consciousness (DoC) require care from multidisciplinary teams with specialized training and expertise in management of the complex needs of this clinical population. The recent promulgation of practice guidelines for patients with prolonged DoC by the American Academy of Neurology, American Congress of Rehabilitation Medicine (ACRM), and National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) represents a major advance in the development of care standards in this area of brain injury rehabilitation. Implementation of these practice guidelines requires explication of the minimum competencies of clinical programs providing services to persons who have DoC. The Brain Injury Interdisciplinary Special Interest Group of the ACRM, in collaboration with the Disorders of Consciousness Special Interest Group of the NIDILRR-Traumatic Brain Injury Model Systems convened a multidisciplinary panel of experts to address this need through the present position statement. Content area-specific workgroups reviewed relevant peer-reviewed literature and drafted recommendations which were then evaluated by the expert panel using a modified Delphi voting process. The process yielded 21 recommendations on the structure and process of essential services required for effective DoC-focused rehabilitation, organized into 4 categories: diagnostic and prognostic assessment (4 recommendations), treatment (11 recommendations), transitioning care/long-term care needs (5 recommendations), and management of ethical issues (1 recommendation). With few exceptions, these recommendations focus on infrastructure requirements and operating procedures for the provision of DoC-focused neurorehabilitation services across subacute and postacute settings.

Paroxysmal Sympathetic Hyperactivity and Clinical Considerations for Patients With Acquired Brain Injuries: A Narrative Review.

The term "storming" has often been used colloquially to characterize patients with brain injury who showed signs and symptoms of elevated heart rate, blood pressure, respiratory rate, temperature, and motor posturing. Recently, the term paroxysmal sympathetic hyperactivity has been used as the unifying term to describe these acute episodes of elevated sympathetic hyperactivity. Various pharmaceutical and management options are available, but no single drug or protocol has been deemed superior to the others. Data on prognosis and recovery in relation to paroxysmal sympathetic hyperactivity are limited but point toward poorer functional outcome and increased mortality. Overall, the phenomenon of paroxysmal sympathetic hyperactivity requires further research to aid rehabilitative efforts so that patients can effectively participate in therapy. A review of the literature has revealed sparse information on the management of sympathetic storming within rehabilitation facilities. This narrative review seeks to provide an up-to-date synopsis and recommendations on the management of rehabilitation inpatients with paroxysmal sympathetic hyperactivity.

Update on Insomnia after Mild Traumatic Brain Injury.

Sleep disturbance after traumatic brain injury (TBI) has received growing interest in recent years, garnering many publications. Insomnia is highly prevalent within the mild traumatic brain injury (mTBI) population and is a subtle, frequently persistent complaint that often goes undiagnosed. For individuals with mTBI, problems with sleep can compromise the recovery process and impede social reintegration. This article updates the evidence on etiology, epidemiology, prognosis, consequences, differential diagnosis, and treatment of insomnia in the context of mild TBI. This article aims to increase awareness about insomnia following mTBI in the hopes that it may improve diagnosis, evaluation, and treatment of sleeping disturbance in this population while revealing areas for future research.

Nonpharmacological management of sleep disturbances after traumatic brain injury.

BACKGROUND: Sleep plays an integral role in several physiologic functions such as cognition and functional ability. Sleep disturbances are common after brain injury and can interfere with rehabilitation and recovery. There are several pathways by which sleep is initiated, and thus various ways to target common complaints as well. OBJECTIVES: To review alternative and non-pharmacological treatment approaches to sleep disorders following TBI. METHODS: The authors present a review of the literature on various alternative treatment methods for treating sleep disorders, and discuss evidence for safety and efficacy. CONCLUSIONS: Typical management include conservative measures and pharmacologic treatment. This article provides a review of the available nonpharmacologic treatment options for sleep disorders in patients with traumatic brain injury. There are a number of non-pharmacological treatment methods available for treatment of sleep disorders in this population.

Autonomic Dysfunction after Mild Traumatic Brain Injury.

A mild traumatic brain injury (mTBI) is a complex pathophysiologic process that has a systemic effect on the body aside from solely an impairment in cognitive function. Dysfunction of the autonomic nervous system (ANS) has been found to induce abnormalities in organ systems throughout the body, and may contribute to cardiovascular dysregulation and increased mortality. Autonomic dysfunction, also known as dysautonomia, has been studied in moderate and severe TBI, and has emerged as a major contributing factor in the symptomatology in mTBI as well. Analysis of the ANS has been studied through changes in heart rate variability (HRV), pupillary dynamics, eye pressure, and arterial pulse wave in those with mild TBI. Graded exercise testing has been studied as both a method of diagnosis and as a means of recovery in those with mild TBI, especially in those with persistent symptoms. Given the studies showing persistence of autonomic dysfunction after symptomatic resolution of concussions, further research is needed to establish return to play protocols.