Neuropsychiatric phenotypes in functional movement disorder.

OBJECTIVE: Functional movement disorder (FMD), the motor-dominant subtype of functional neurological disorder, is a complex neuropsychiatric condition. Patients with FMD also manifest non-motor symptoms. Given that patients with FMD are diagnosed based on motor phenotype, the contribution of non-motor features to the neuropsychiatric syndrome is not well characterized. The objective of this hypothesis-generating study was to explore potential novel, neuropsychiatric FMD phenotypes by combining movement disorder presentations with non-motor comorbidities including somatic symptoms, psychiatric diagnoses, and psychological traits. METHODS: This retrospective chart review evaluated 158 consecutive patients with a diagnosis of FMD who underwent deep phenotyping across neurological and psychiatric domains. Demographic, clinical, and self-report features were analyzed. A data-driven approach using cluster analysis was performed to detect patterns when combining the movement disorder presentation with somatic symptoms, psychiatric diagnoses, and psychological factors. These new neuropsychiatric FMD phenotypes were then tested using logistic regression models. RESULTS: Distinct neuropsychiatric FMD phenotypes emerged when stratifying by episodic vs. constant motor symptoms. Episodic FMD was associated with hyperkinetic movements, hyperarousal, anxiety, and history of trauma. In contrast, constant FMD was associated with weakness, gait disorders, fixed dystonia, activity avoidance, and low self-agency. Pain, fatigue, somatic preoccupation, and health anxiety were common across all phenotypes. CONCLUSION: This study found patterns spanning the neurological-psychiatric interface that indicate that FMD is part of a broader neuropsychiatric syndrome. Adopting a transdisciplinary view of illness reveals readily identifiable clinical factors that are relevant for the development and maintenance of FMD.

Optimizing early education provided at the Hull-Ellis Concussion and Research Clinic: A multiple methods evaluation from the Toronto Concussion Study.

OBJECTIVES: The purpose of this study was to determine factors and characteristics associated with changes in knowledge among adults receiving education within the first 8 weeks post-concussion. The study also aimed to understand desired preferences (i.e. content, format) for education post-concussion from the perspective of patients and physicians. METHODS: Patient-participants (17-85 years) were prospectively recruited within one week of a concussion. Participants received education over visits from Weeks 1 to 8 post-injury. Primary outcome measures were participant responses on a concussion knowledge questionnaire at Weeks 1 (n = 334) and 8 (n = 195), and feedback regarding education through interviews. Other variables collected included preexisting medical history, physician assessed recovery and symptoms. RESULTS: There was a significant increase in average knowledge on the concussion knowledge questionnaire across time (71% vs 75% correct; p = 0.004). Participants with higher levels of education, female sex and preexisting diagnoses of depression or anxiety had more correct responses at Week 1. Healthcare providers had varying comfort levels addressing mood-related symptoms. CONCLUSIONS: There is a need to tailor education provided to concussion patients based on preinjury characteristics, i.e., mood disorders and demographic factors. Healthcare providers may need additional training in addressing mood symptoms and should modify the approach to fit patients' unique needs.

Revisiting the ICHD-3 criteria for headache attributed to mild traumatic injury to the head: Insights from the Toronto Concussion Study Analysis of Acute Headaches Following Concussion.

BACKGROUND: There is limited prospective data on the prevalence, timing of onset, and characteristics of acute headache following concussion/mild traumatic brain injury. METHODS: Adults diagnosed with concussion (arising from injuries not related to work or motor vehicle accidents) were recruited from emergency departments and seen within one week post injury wherein they completed questionnaires assessing demographic variables, pre-injury headache history, post-injury headache history, and the Sport Concussion Assessment Tool (SCAT-3) symptom checklist, the Sleep and Concussion Questionnaire (SCQ) and mood/anxiety on the Brief Symptom Inventory (BSI). RESULTS: A total of 302 participants (59% female) were enrolled (mean age 33.6 years) and almost all (92%) endorsed post-traumatic headache (PTH) with 94% endorsing headache onset within 24 hours of injury. Headache location was not correlated with site of injury. Most participants (84%) experienced daily headache. Headache quality was pressure/squeezing in 69% and throbbing/pulsing type in 22%. Associated symptoms included: photophobia (74%), phonophobia (72%) and nausea (55%). SCAT-3 symptom scores, Brief Symptom Inventory and Sleep and Concussion Questionnaire scores were significantly higher in those endorsing acute PTH. No significant differences were found in week 1 acute PTH by sex, history of migraine, pre-injury headache frequency, anxiety, or depression, nor presence/absence of post-traumatic amnesia and self-reported loss of consciousness. CONCLUSIONS: This study highlights the very high incidence of acute PTH following concussion, the timing of onset and characteristics of acute PTH, the associated psychological and sleep disturbances and notes that the current ICHD-3 criteria for headaches attributed to mild traumatic injury to the head are reasonable, the interval between injury and headache onset should not be extended beyond seven days and could, potentially, be shorted to allow for greater diagnostic precision.

Medical Care Among Individuals with a Concussion in Ontario: A Population-based Study.

BACKGROUND: Concussion affects 1.2% of the population annually; rural regions and children have higher rates of concussion. METHODS: Using administrative health care linked databases, all residents of Ontario with a physician diagnosed concussion were identified using ICD-9 code 850 or ICD-10 code S06. Cases were tracked for 2 years for concussion-related health care utilization with relevant specialist physicians (i.e., neurology, otolaryngology, physiatry, psychiatry, ophthalmology). Billing codes, specialist codes, and time from index to visit were analyzed. Factors associated with increased specialist visits were also examined. RESULTS: In total, 1,022,588 cases were identified between 2008 and 2014 with 2 years of post-concussion health care utilization available. Follow-up by physician within 3 days of injury occurred in only 14% of cases. Mean time between ED diagnosis and follow-up by a physician was 83.9 days, whereas for rural regions it was >100 days. About half of adults (51.9%) and children (50.3%) had at least 1 specialist visit following concussion. Mean time between injury and first specialist visit was 203.8 (SD 192.9) days for adults, 213.5 (SD 201.0) days for rural adults, and 276.0 (SD 202.6) days for children. There were 67,420 neurology visits, 70,404 psychiatry visits, 13,571 neurosurgery visits, 19,780 physiatry visits, 101,788 ENT visits, and 103,417 ophthalmology visits in the 2 years tracking period. Factors associated with more specialist use included age > 18 years, urban residence, and pre-injury psychiatric history. CONCLUSIONS: There are discrepancies in post-concussion health care utilization based on age group and rural/urban residence. Addressing these risk factors could improve concussion care access.

The Toronto Concussion Study: Sense of smell is not associated with concussion severity or recovery.

OBJECTIVE: To examine sense of smell as a biomarker for both severity and duration of post-concussion symptoms. METHODS: Participants were recruited prospectively from an outpatient concussion clinic. Sense of smell was assessed using the University of Pennsylvania Smell Identification Test (UPSIT) within 7 days, and 4, 8 - or 16-weeks post-injury. UPSIT normative data were used as normal controls. The main outcomes were: symptom severity on the Sport Concussion Assessment Tool 3 (SCAT3) symptom inventory and time to physician-declared recovery. RESULTS: A total of 167 participants (mean age 32.9 [SD, 12.2] years, 59% female [n = 99]) were classified at 1 week post injury as follows: severe hyposmia in 5 (3%), moderate hyposmia in 10 (6%), mild hyposmia in 48 (29%), and normosmia in 104 (62%) individuals. A convenience sample of 81 individuals with concussion were tested at follow-up. Acute impairment of sense of smell following concussion was not associated with symptom severity on the SCAT3 or time to recovery. Sense of smell was stable from baseline to follow-up in this population. CONCLUSION: This study provides evidence that routine testing of sense of smell in individuals with concussion is not warranted as a biomarker for severity of concussion and concussion recovery.

Prediction of risk of prolonged post-concussion symptoms: Derivation and validation of the TRICORDRR (Toronto Rehabilitation Institute Concussion Outcome Determination and Rehab Recommendations) score.

BACKGROUND: Approximately 10% to 20% of people with concussion experience prolonged post-concussion symptoms (PPCS). There is limited information identifying risk factors for PPCS in adult populations. This study aimed to derive a risk score for PPCS by determining which demographic factors, premorbid health conditions, and healthcare utilization patterns are associated with need for prolonged concussion care among a large cohort of adults with concussion. METHODS AND FINDINGS: Data from a cohort study (Ontario Concussion Cohort study, 2008 to 2016; n = 1,330,336) including all adults with a concussion diagnosis by either primary care physician (ICD-9 code 850) or in emergency department (ICD-10 code S06) and 2 years of healthcare tracking postinjury (2008 to 2014, n = 587,057) were used in a retrospective analysis. Approximately 42.4% of the cohort was female, and adults between 18 and 30 years was the largest age group (31.0%). PPCS was defined as 2 or more specialist visits for concussion-related symptoms more than 6 months after injury index date. Approximately 13% (73,122) of the cohort had PPCS. Total cohort was divided into Derivation (2009 to 2013, n = 417,335) and Validation cohorts (2009 and 2014, n = 169,722) based upon injury index year. Variables selected a priori such as psychiatric disorders, migraines, sleep disorders, demographic factors, and pre-injury healthcare patterns were entered into multivariable logistic regression and CART modeling in the Derivation Cohort to calculate PPCS estimates and forward selection logistic regression model in the Validation Cohort. Variables with the highest probability of PPCS derived in the Derivation Cohort were: Age >61 years ([Formula: see text] = 0.54), bipolar disorder ([Formula: see text] = 0.52), high pre-injury primary care visits per year ([Formula: see text] = 0.46), personality disorders ([Formula: see text] = 0.45), and anxiety and depression ([Formula: see text] = 0.33). The area under the curve (AUC) was 0.79 for the derivation model, 0.79 for bootstrap internal validation of the Derivation Cohort, and 0.64 for the Validation model. A limitation of this study was ability to track healthcare usage only to healthcare providers that submit to Ontario Health Insurance Plan (OHIP); thus, some patients seeking treatment for prolonged symptoms may not be captured in this analysis. CONCLUSIONS: In this study, we observed that premorbid psychiatric conditions, pre-injury health system usage, and older age were associated with increased risk of a prolonged recovery from concussion. This risk score allows clinicians to calculate an individual's risk of requiring treatment more than 6 months post-concussion.

Reduced microglia activity in patients with long-term immunosuppressive therapy after liver transplantation.

PURPOSE: Calcineurin inhibitors (CNI) can cause long-term impairment of brain function. Possible pathomechanisms include alterations of the cerebral immune system. This study used positron emission tomography (PET) imaging with the translocator protein (TSPO) ligand 18F-GE-180 to evaluate microglial activation in liver-transplanted patients under different regimens of immunosuppression. METHODS: PET was performed in 22 liver-transplanted patients (3 CNI free, 9 with low-dose CNI, 10 with standard-dose CNI immunosuppression) and 9 healthy controls. The total distribution volume (VT) estimated in 12 volumes-of-interest was analyzed regarding TSPO genotype, CNI therapy, and cognitive performance. RESULTS: In controls, VT was about 80% higher in high affinity binders (n = 5) compared to mixed affinity binders (n = 3). Mean VT corrected for TSPO genotype was significantly lower in patients compared to controls, especially in patients in whom CNI dose had been reduced because of nephrotoxic side effect. CONCLUSION: Our results provide evidence of chronic suppression of microglial activity in liver-transplanted patients under CNI therapy especially in patients with high sensitivity to CNI toxicity.

Dissecting the target leukocyte subpopulations of clinically relevant inflammation radiopharmaceuticals.

BACKGROUND: Leukocyte subtypes bear distinct pro-inflammatory, reparative, and regulatory functions. Imaging inflammation provides information on disease prognosis and may guide therapy, but the cellular basis of the signal remains equivocal. We evaluated leukocyte subtype specificity of characterized clinically relevant inflammation-targeted radiotracers. METHODS AND RESULTS: Leukocyte populations were purified from blood- and THP-1-derived macrophages were polarized into M1-, reparative M2a-, or M2c-macrophages. In vitro uptake assays were conducted using tracers of enhanced glucose or amino acid metabolism and molecular markers of inflammatory cells. Both 18F-deoxyglucose (18F-FDG) and the labeled amino acid 11C-methionine (11C-MET) displayed higher uptake in neutrophils and monocytes compared to other leukocytes (P = 0.005), and markedly higher accumulation in pro-inflammatory M1-macrophages compared to reparative M2a-macrophages (P < 0.001). Molecular tracers 68Ga-DOTATATE targeting the somatostatin receptor type 2 and 68Ga-pentixafor targeting the chemokine receptor type 4 (CXCR4) exhibited broad uptake by leukocyte subpopulations and polarized macrophages with highest uptake in T-cells/natural killer cells and B-cells compared to neutrophils. Mitochondrial translocator protein (TSPO)-targeted 18F-flutriciclamide selectively accumulated in monocytes and pro-inflammatory M1 macrophages (P < 0.001). Uptake by myocytes and fibroblasts tended to be higher for metabolic radiotracers. CONCLUSIONS: The different in vitro cellular uptake profiles may allow isolation of distinct phases of the inflammatory pathway with specific inflammation-targeted radiotracers. The pathogenetic cell population in specific inflammatory diseases should be considered in the selection of an appropriate imaging agent.

Reliable quantification of 18F-GE-180 PET neuroinflammation studies using an individually scaled population-based input function or late tissue-to-blood ratio.

PURPOSE: Tracer kinetic modeling of tissue time activity curves and the individual input function based on arterial blood sampling and metabolite correction is the gold standard for quantitative characterization of microglia activation by PET with the translocator protein (TSPO) ligand 18F-GE-180. This study tested simplified methods for quantification of 18F-GE-180 PET. METHODS: Dynamic 18F-GE-180 PET with arterial blood sampling and metabolite correction was performed in five healthy volunteers and 20 liver-transplanted patients. Population-based input function templates were generated by averaging individual input functions normalized to the total area under the input function using a leave-one-out approach. Individual population-based input functions were obtained by scaling the input function template with the individual parent activity concentration of 18F-GE-180 in arterial plasma in a blood sample drawn at 27.5 min or by the individual administered tracer activity, respectively. The total 18F-GE-180 distribution volume (VT) was estimated in 12 regions-of-interest (ROIs) by the invasive Logan plot using the measured or the population-based input functions. Late ROI-to-whole-blood and ROI-to-cerebellum ratio were also computed. RESULTS: Correlation with the reference VT (with individually measured input function) was very high for VT with the population-based input function scaled with the blood sample and for the ROI-to-whole-blood ratio (Pearson correlation coefficient = 0.989 ± 0.006 and 0.970 ± 0.005). The correlation was only moderate for VT with the population-based input function scaled with tracer activity dose and for the ROI-to-cerebellum ratio (0.653 ± 0.074 and 0.384 ± 0.177). Reference VT, population-based VT with scaling by the blood sample, and ROI-to-whole-blood ratio were sensitive to the TSPO gene polymorphism. Population-based VT with scaling to the administered tracer activity and the ROI-to-cerebellum ratio failed to detect a polymorphism effect. CONCLUSION: These results support the use of a population-based input function scaled with a single blood sample or the ROI-to-whole-blood ratio at a late time point for simplified quantitative analysis of 18F-GE-180 PET.

Increasing Incidence of Concussion: True Epidemic or Better Recognition?

OBJECTIVES: To provide updated estimates of the incidence of concussion from all causes diagnosed by all physicians in a large jurisdiction, as previous studies have examined only single causes of injury or from smaller specific populations. DESIGN: Physician Billing and National Ambulatory Care Reporting System (NACRS) databases were used to identify all Ontario residents with a diagnosis of concussion (ICD-9 850.0 and ICD-10 S06.0) made by physicians between 2008 and 2016, excluding those with moderate to severe traumatic brain injury. RESULTS: In total, 1 330 336 people were diagnosed with a concussion between 2008 and 2016. The annual average was 147 815, and 79% were diagnosed in the emergency department. The average annual incidence was 1153 per 100 000 residents. Incidence varied by age, sex, and geography; children younger than 5 years had the highest incidence of concussion, more than 3600 per 100 000 individuals of that age group. Males had higher incidence than females except in older than 65 years age groups. There was a Pearson correlation (+0.669) between sustaining a concussion and living in rural locations. CONCLUSION: The annual incidence of approximately 1.2% of the population is the highest rate of concussion ever reported thorough sampling methods and may represent a closer estimate of the true picture of concussion. Findings may inform future concussion treatment and healthcare planning.

Cannabis, alcohol and cigarette use during the acute post-concussion period.

Objective: To document the prevalence of acute post-concussion cannabis, alcohol and cigarette use and their association with clinical recovery and symptom burden.Methods: A prospective cohort study was conducted. Concussions were physician-diagnosed and presented to the emergency department and concussion clinic within 7 days post-injury. Participants were assessed weekly and followed for a minimum 4 weeks. A survival analysis (using physician-determined recovery to both cognitive and physical activities) in addition to a weekly symptom score analysis was conducted.Results: A total of 307 acute concussions with a mean age of 33.7 years (SD, 13.0) were included. Acute post-concussion cannabis, alcohol and cigarette use were identified in 43 (14.0%), 125 (40.7%) and 61 (19.9%) individuals. Acute cannabis, alcohol and cigarette use were not associated with recovery to cognitive (p > .05) or physical activity (p > .05). Acute cigarette use was associated with a higher unadjusted symptom severity score at week1 (p = .003). Acute cannabis use was associated with lower symptom severity scores at week-3 (p = .061) and week-4 (p = .029).Conclusion: In conclusion, cannabis, alcohol and cigarette use were prevalent in the acute period post-concussion; however, were not observed to impact recovery within the first 4 weeks post-injury. Amongst unrecovered individuals, acute cannabis use was associated with lower symptom burden, while cigarette use was associated with greater initial symptom burden.

Factors Influencing Triage to Rehabilitation in Functional Movement Disorder.

BACKGROUND: Treatment of functional movement disorder (FMD) should be individualized, yet factors determining rehabilitation engagement have not been evaluated. Subspecialty FMD clinics are uniquely poised to explore factors influencing treatment suitability and triage. OBJECTIVES: To describe our approach and explore factors associated with triage to FMD rehabilitation. METHODS: We conducted a retrospective chart review of 158 consecutive patients with FMD seen for integrated assessment by movement disorders neurology and psychiatry, with the purpose of triage to rehabilitation. Demographic and clinical variables were compared between patients triaged to therapy versus no therapy, and logistic regression was used to explore factors predictive of triage outcome. Change in primary outcome scores were analyzed. RESULTS: Sixty-six patients (42%) were triaged to FMD therapy from July 2019 to December 2021. Patients triaged to therapy were more likely to have a constant movement disorder, gait disorder and/or tremor, hyperarousal, readiness for change, and people pleasing traits. Patients triaged to no therapy demonstrated persistent diagnostic disagreement, an inability to appreciate motor symptom inconsistency, low self-agency, a propensity to dissociate, and cluster B traits. 90% of patients triaged to rehabilitation had improved outcomes. CONCLUSIONS: The ability to "opt-in" to FMD rehabilitation relies on different factors than those relevant to establishing a diagnosis. Unlike many other neurological disorders, a triage and treatment planning step is recommended to identify those likely to meaningfully engage at that time. Holistic assessment through a transdisciplinary lens, and working collaboratively with the patient is essential to prioritize symptoms, determine engagement, and identify treatment targets.

Integrated model of care for functional movement disorder: targeting brain, mind and body.

PURPOSE: To describe the therapy approaches and clinical outcomes of an integrated care model for patients with functional movement disorder (FMD). MATERIALS AND METHODS: A retrospective chart review was conducted for all treated individuals with a primary diagnosis of FMD between January 2020 and July 2022. Patients received time-limited integrated therapy (n = 21) (i.e., simultaneous therapy delivered by psychiatry, neurology and physiotherapy), physiotherapy (n = 18) or virtual physiotherapy alone (n = 9). Primary outcomes included the Simplified-Functional Movement Disorders Rating Scale (S-FMDRS) and Clinical Global Impression-Improvement scale (CGI-I) collected at baseline and post-intervention. RESULTS: Forty-eight patients completed treatment (42% male; mean age, 48.5 ± 16.6 years, median symptom duration 30 months). The most common presentations were gait disorder, tremor and mixed hyperkinetic FMD. Common comorbidities included pain and fatigue. Three-quarters of patients had a comorbid psychiatric diagnosis. There was a significant reduction in S-FMDRS score following therapy (71%, p < 0.0001) and 69% had "much" or "very much" improved on the CGI-I. There was no difference between therapy groups. Attendance rates were high for both in-person (94%) and virtual (97%) visits. CONCLUSIONS: These findings support that a time-limited integrated model of care is feasible and effective in treating patients with FMD.

An integrated approach that draws from both mental health and physiotherapy-oriented strategies reframes functional movement disorder treatment targets and clinical outcomes, influences triage criteria, and produces new and innovative therapies.Successful outcomes depend on triaging suitable participants and individualized treatment plans that focus on functional goals.Virtual telerehabilitation in functional movement disorder is effective and offers the opportunity to work with patients in real-time in the environment where they most often experience functional neurological symptoms.

The Incidence and Nature of Adverse Events During Inpatient Rehabilitation: A Retrospective Case Series.

OBJECTIVE: To describe and compare adverse event (AE) incidence, type, severity, and preventability in the Canadian inpatient rehabilitation setting. DESIGN: In this retrospective case series, AEs were identified through chart reviews from two Canadian academic tertiary post-acute care hospitals. AEs were characterized through descriptive statistics and compared using the Mantel-Haenszel and Fisher's exact tests. RESULTS: During the study period, one site (n = 120) had 28 AEs and an incidence of 9.7 (95% CI 6.1-13.3) per 1000 patient days, and the other (n = 48) had 15 AEs and an incidence of 13.9 (95% CI 6.9-21) per 1000 patient days (p = 0.82). The two sites differed significantly in AE type (p = 0.033) and preventability (p = 0.002) but not severity. The most common AE type was medication/intravenous fluids-related (16/28, 57%) at one site and patient incidents (e.g., falls, pressure ulcers) at the other. Four percent (1/28) of AEs were preventable at one site, and 53% (8/15) at another. Most AEs at both sites were mild in severity. CONCLUSIONS: AEs significantly differed in type and preventability between the two sites. These results suggest the importance of context and the need for an organization-specific and tailored approach when addressing patient safety in inpatient rehabilitation settings.

A retrospective study of morbidity and mortality of chronic acid sphingomyelinase deficiency in Germany.

BACKGROUND: Acid sphingomyelinase deficiency (ASMD) is a rare, progressive, potentially fatal lysosomal storage disease that exhibits a broad spectrum of clinical phenotypes. There is a need to expand the knowledge of disease mortality and morbidity in Germany because of limited information on survival analysis in patients with chronic ASMD (type B or type A/B). METHODS: This observational, multicentre, retrospective cohort study was conducted using medical records of patients with the first symptom onset/diagnosis of ASMD type B or type A/B between 1st January 1990 and 31st July 2021 from four German medical centres. Eligible medical records were abstracted to collect data on demographic characteristics, medical history, hospitalisation, mortality, and causes of death from disease onset to the last follow-up/death. Survival outcomes were estimated using the Kaplan-Meier analysis. Standardised mortality ratio (SMR) was also explored. RESULTS: This study included 33 chart records of patients with ASMD type B (n = 24) and type A/B (n = 9), with a median (interquartile range [IQR]) age of 8.0 [3.0-20.0] years and 1.0 [1.0-2.0] years, respectively, at diagnosis. The commonly reported manifestations were related to spleen (100.0%), liver (93.9%), and respiratory (77.4%) abnormalities. Nine deaths were reported at a median [IQR] age of 17.0 [5.0-25.0] years, with 66.7% of overall patients deceased at less than 18 years of age; the median [IQR] age at death for patients with ASMD type B (n = 4) and type A/B (n = 5) was 31.0 [11.0-55.0] and 9.0 [4.0-18.0] years, respectively. All deaths were ASMD-related and primarily caused by liver or respiratory failures or severe progressive neurodegeneration (two patients with ASMD type A/B). The median (95% confidence interval [CI]) overall survival age since birth was 45.4 (17.5-65.0) years. Additionally, an SMR [95% CI] analysis (21.6 [9.8-38.0]) showed that age-specific deaths in the ASMD population were 21.6 times more frequent than that in the general German population. CONCLUSIONS: This study highlights considerable morbidity and mortality associated with ASMD type B and type A/B in Germany. It further emphasises the importance of effective therapy for chronic ASMD to reduce disease complications.

A systematic review and meta-analysis exploring the efficacy of mindfulness-based interventions on quality of life in people with multiple sclerosis.

BACKGROUND: Quality of life (QoL) is commonly impaired among people with multiple sclerosis (PwMS). The aim of this study was to evaluate via meta-analysis the efficacy of Mindfulness-based interventions (MBIs) for improving QoL in PwMS. METHODS: Eligible randomized controlled trials (RCTs) were identified via searching six major electronic databases (MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, AMED, and PsycINFO) in April 2022. The primary outcome was QoL. Study quality was determined using the Cochrane Collaboration risk of bias tool. Meta-analysis using a random effects model was undertaken. Effect sizes are reported as Standardized Mean Difference (SMD). Prospero ID: 139835. RESULTS: From a total of 1312 individual studies, 14 RCTs were eligible for inclusion in the meta-analysis, total participant n = 937. Most studies included PwMS who remained ambulatory. Cognitively impaired PwMS were largely excluded. Comorbidities were inconsistently reported. Most MBIs were delivered face-to face in group format, but five were online. Eight studies (n = 8) measured MS-specific QoL. In meta-analysis, overall effect size (SMD) for any QoL measure (n = 14) was 0.40 (0.18-0.61), p = 0.0003, I2 = 52%. SMD for MS-specific QoL measures (n = 8) was 0.39 (0.21-0.57), p < 0.0001, I2 = 0%. MBI effect was largest on subscale measures of mental QoL (n = 8), SMD 0.70 (0.33-1.06), p = 0.0002, I2 = 63%. Adverse events were infrequently reported. CONCLUSIONS: MBIs effectively improve QoL in PwMS. The greatest benefits are on mental health-related QoL. However, more research is needed to characterize optimal formatting, mechanisms of action, and effects in PwMS with more diverse social, educational, and clinical backgrounds.

The Toronto Concussion Study: a prospective investigation of characteristics in a cohort of adults from the general population seeking care following acute concussion, 2016-2020.

Purpose: There is limited research regarding the characteristics of those from the general population who seek care following acute concussion. Methods: To address this gap, a large cohort of 473 adults diagnosed with an acute concussion (female participants = 287; male participants = 186) was followed using objective measures prospectively over 16 weeks beginning at a mean of 5.1 days post-injury. Results: Falls were the most common mechanism of injury (MOI) (n = 137, 29.0%), followed by sports-related recreation (n = 119, 25.2%). Male participants were more likely to be injured playing recreational sports or in a violence-related incident; female participants were more likely to be injured by falling. Post-traumatic amnesia (PTA) was reported by 80 participants (16.9 %), and loss of consciousness (LOC) was reported by 110 (23.3%). In total, 54 participants (11.4%) reported both PTA and LOC. Male participants had significantly higher rates of PTA and LOC after their injury compared to their female counterparts. Higher initial symptom burden was associated with a longer duration of recovery for both male and female participants. Female participants had more symptoms and higher severity of symptoms at presentation compared to male participants. Female participants were identified to have a longer recovery duration, with a mean survival time of 6.50 weeks compared to 5.45 weeks in male participants (p < 0.0001). A relatively high proportion of female and male participants in this study reported premorbid diagnoses of depression and anxiety compared to general population characteristics. Conclusion: Although premorbid diagnoses of depression and/or anxiety were associated with higher symptom burden at the initial visit, the duration of symptoms was not directly associated with a pre-injury history of psychological/psychiatric disturbance. This cohort of adults, from the general population, seeking care for their acute concussion attained clinical and functional recovery over a period of 4-12 weeks.

Characterizing Sleep and Wakefulness in the Acute Phase of Concussion in the General Population: A Naturalistic Cohort from the Toronto Concussion Study.

Growing literature links concussion to changes in sleep and wakefulness in humans and in rodent models. Sleep has been linked with synaptic reorganization under other conditions; however, the characterization and role of sleep after acute concussion remains poorly understood. While much research has focused on insomnia among patients with chronic or persistent concussion symptoms, there is limited understanding of sleep and acute concussion, its potential role in recovery, and associated risk factors for the development of chronic sleep disturbance. Studies to date are limited by small sample sizes of primarily athlete or military populations. Additional studies among the general population are critical to inform best practice guidelines. We examined the sleep and daytime wakefulness of 472 adults from a naturalistic general population cohort (mean age, 33.3 years, females = 60.8%) within seven days of diagnosed concussion, using a validated, condition-specific measure, the Sleep and Concussion Questionnaire. Participants identified immediate changes in sleep characterized by hypersomnia and difficulty maintaining daytime wakefulness; 35% considered these changes as moderate to severe and 79% required monitoring or follow-up. Females experienced significantly greater severity of changes in sleep compared with males. Positive correlations between severity of sleep and pain and headache were identified. Differences by sex are an important consideration for early intervention and long-term monitoring. Because sleep was compromised by pain, pain management is also an integral part of early intervention. Our findings suggest that assessment of sleep beginning in the acute stage is a critical component of concussion management in the general population.

Perceptions of patients and nurses regarding the use of wearables in inpatient settings: a mixed methods study.

Wearable devices for hospitalized patients could help improve care. The purpose of this study was to highlight key barriers and facilitators involved in adopting wearable technology in acute care settings using patient and clinician feedback. Hospitalized patients, 18 years or older, were recruited at the General Medicine inpatient units in Toronto, Ontario to wear the Fitbit® Charge 2 or Charge 3. Fifty General Medicine adult inpatients were recruited. Patients and nurses provided feedback on structured questionnaires. Key themes from open-ended questions were analyzed. Primary outcomes of interest included the exploring patient and nurse perceptions of their experiences with wearable devices as well as their feasibility in clinical settings. Overall, both patients (n = 39) and nurses (n = 28) valued the information provided by Fitbits and shared concerns about device functionality and wearable design. Specifically, patients were interested in using wearables to enhance their self-monitoring, while nurses questioned data validity, as well as ease of incorporating wearables into their workflow. We found that patients wanted improved device design and functionality and valued the opportunity to improve their self-efficacy and to work in partnership with the medical team using wearable technology. Nurses wanted more device functionality and validation and easier ways to incorporate them into their workflow. To achieve the potential benefits of using wearable devices for enhanced monitoring, this study identifies challenges that must first be addressed in order for this technology to be widely adopted in clinical settings.

Examining the Relationship Between Community Integration and Mental Health Characteristics of Individuals With Childhood Acquired Neurological Disability.

Background: Many individuals with cerebral palsy (CP) or acquired brain injury (ABI) are at higher risk of lowered psychosocial functioning, poor mental health outcomes and decreased opportunities for community integration (CI) as they transition to adulthood. It is imperative to understand the characteristics of those at highest risk of dysfunction so that targeted interventions can be developed to reduce the impact. Methods: This quantitative, cross-sectional study examines current patients of the Living Independently Fully Engaged [(LIFEspan) Service], a tertiary outpatient hospital-based clinic. The Patient Health Questionnaire-4 (PHQ-4) and the Community Integration Questionnaire (CIQ) were administered to participants. Personal health information was also collected from participants' health charts, and participant interviews. Associations of sex and condition with the outcomes of screening for further assessment of depression, screening for further assessment of anxiety, and CI were calculated using t-tests and Chi-square tests. Results: 285 participants completed standardized screening tools for depression and anxiety (PHQ-4) and 283 completed the Community Integration Questionnaire (CIQ). Mean age was 23.4 (4.2) years; 59% were diagnosed with CP, 41% diagnosed with ABI, and 56% were male. A moderate proportion of the sample screened positive for further assessment of anxiety (28%) and depression (16%), and the overall mean score on the CIQ for the sample was 15.8 (SD 5.1). Participants that screened positive for further assessment of depression and anxiety on the PHQ-4 had lower scores on the Social Integration subscale of the CIQ (p = 0.04 and p = 0.036, respectively). Females were found to have significantly higher community integration than males (p = 0.0011) and those diagnosed with ABI were found to have significantly higher community integration than those with CP (p = 0.009), respectively. A weak negative association was found between age for the total sample and overall PHQ-4 score (p = 0.0417). Presence of an intellectual or learning disability/challenge was associated with a lower CIQ score (p = 0.0026). Conclusions: This current study, highlights the need for further research to explore the unique needs and barriers faced by this population. This study may inform assessments and interventions to support the mental health and community integration of this population.