Associations Between Traumatic Brain Injury, Suspected Psychiatric Conditions, and Unemployment in Operation Enduring Freedom/Operation Iraqi Freedom Veterans.

OBJECTIVE: To examine the relations among demographic characteristics, traumatic brain injury (TBI) history, suspected psychiatric conditions, current neurobehavioral health symptoms, and employment status in Veterans evaluated for TBI in the Department of Veterans Affairs. STUDY DESIGN: Retrospective cross-sectional database review of comprehensive TBI evaluations documented between October 2007 and June 2009. PARTICIPANTS: Operation Enduring Freedom/Operation Iraqi Freedom Veterans (n = 11 683) who completed a comprehensive TBI evaluation. MAIN MEASURES: Veterans Affairs clinicians use the comprehensive TBI evaluations to obtain information about TBI-related experiences, current neurobehavioral symptoms, and to identify suspected psychiatric conditions. RESULTS: Approximately one-third of Veterans in this sample were unemployed, and of these, the majority were looking for work. After simultaneously adjusting for health and deployment-related variables, significant factors associated with unemployment included one or more suspected psychiatric conditions (eg, posttraumatic stress disorder, anxiety, depression), neurobehavioral symptom severity (ie, affective, cognitive, vestibular), former active duty status, injury etiology, age, lower education, and marital status. The associations of these factors with employment status varied by deployment-related TBI severity. CONCLUSIONS: Simultaneously addressing health-related, educational, and/or vocational needs may fill a critical gap for helping Veterans readjust to civilian life and achieve their academic and vocational potential.

Screening for mild traumatic brain injury in OEF-OIF deployed US military: an empirical assessment of VHA's experience.

BACKGROUND: VHA screens for traumatic brain injury (TBI) among patients formerly deployed to Afghanistan or Iraq, referring those who screen positive for a Comprehensive TBI Evaluation (CTBIE). METHODS: To assess the programme, rates were calculated of positive screens for potential TBI in the population of patients screened in VHA between October 2007 through March 2009. Rates were derived of TBI confirmed by comprehensive evaluations from October 2008 through July 2009. Patient characteristics were obtained from Department of Defense and VHA administrative data. RESULTS: In the study population, 21.6% screened positive for potential TBI and 54.6% of these had electronic records of a CTBIE. Of those with CTBIE records, evaluators confirmed TBI in 57.7%, yielding a best estimate that 6.8% of all those screened were confirmed to have TBI. Three quarters of all screened patients and virtually all those evaluated (whether TBI was confirmed or not) had VHA care the following year. CONCLUSIONS: VHA's TBI screening process is inclusive and has utility in referring patients with current symptoms to appropriate care. More than 90% of those evaluated received further VHA care and confirmatory evaluations were associated with significantly higher average utilization. Generalizability is limited to those who seek VHA healthcare.

Conducting a Scoping Review in Physical Medicine and Rehabilitation.

ABSTRACT: In the field of physical medicine and rehabilitation, there is a continuous need to conduct literature search in advancing evidence-based practice. In addition to the traditional meta-analysis approach, many clinicians have turned their attention to systematic reviews and scoping reviews for research evidence to support clinical practice. In this article, the authors aimed to (1) compare the similarities, differences, pros, and cons between a scoping review, a systematic review, and a meta-analysis and (2) summarize the fundamental stages in conducting a scoping review. Examples of recently published articles relevant to physical medicine and rehabilitation are presented to illustrate the concept and value of scoping reviews.

Prevalence of dual sensory impairment and its association with traumatic brain injury and blast exposure in OEF/OIF veterans.

OBJECTIVE: To describe the prevalence of self-reported rates of auditory, visual, and dual sensory impairment (DSI) in Afghanistan and Iraq war Veterans receiving traumatic brain injury (TBI) evaluations. DESIGN: Retrospective medical chart review. PARTICIPANTS: Thirty-six thousand nine hundred nineteen Veterans who received a TBI evaluation between October 2007 and June 2009. Final sample included 12,521 subjects judged to have deployment-related TBI and a comparison group of 9106 participants with no evidence of TBI. MAIN OUTCOME MEASURE: Self-reported auditory and visual impairment. RESULTS: Self-reported sensory impairment rates were: 34.6% for DSI, 31.3% for auditory impairment only, 9.9% for visual impairment only, and 24.2% for none/mild sensory impairment. Those with TBI and blast exposure had highest rate of DSI. Regression analyses showed that auditory impairment was the strongest predictor of visual impairment, and vice versa, suggesting these impairments may derive from a common source. CONCLUSIONS: Veterans who self-report clinically significant hearing or vision difficulty during routine TBI evaluation should be evaluated systematically and comprehensively to determine the extent of sensory impairment. Identifying DSI could allow clinicians to collaborate and maximize rehabilitation.

Telerehabilitation for Geriatrics.

Advancements in medical science and technology, along with global increases in life expectancy, are changing the way health care services are delivered to the aging society. Telerehabilitation refers to rehabilitation services involving evaluation and treatment. It is an attractive option for older adults who may have multiple comorbidities. Limited access to in-person services and the concern about potential exposure to severe acute respiratory syndrome coronavirus-2 during this pandemic accelerated the implementation of telerehabilitation. This article review the scope, need, and implementation of telehealth and telerehabilitation in the aging population from the perspective of clinicians, patients, and caregivers.

Recent Advances in the Treatment of Spasticity: Extracorporeal Shock Wave Therapy.

Spasticity is a common sequala of the upper motor neuron lesions. For instance, it often occurs in the first 4 weeks after stroke and is seen in more than one-third of stroke survivors after 12 months. In recent years, extracorporeal shock wave therapy (ESWT) has been recognized as a safe and effective method for reducing muscle spasticity. Possible/relevant mechanisms include nitric oxide production, motor neuron excitability reduction, induction of neuromuscular transmission dysfunction, and direct effects on rheological properties. There are two types of ESWT, focused and radial, with the radial type more commonly applied for treating muscle spasticity. Concerning the optimal location for applying ESWT, the belly muscles and myotendinous junction seem to produce comparable results. The effects of ESWT on spasticity are known to last at least four to six weeks, while some studies report durations of up to 12 weeks. In this review, the authors will focus on the current evidence regarding the effectiveness of ESWT in spasticity, as well as certain technical parameters of ESWT, e.g., the intensity, frequency, location, and number of sessions. The pertinent literature has been reviewed, with an emphasis on post-stroke upper limbs, post-stroke lower limbs, cerebral palsy, and multiple sclerosis. In short, while ESWT has positive effects on parameters such as the modified Ashworth scale, mixed results have been reported regarding functional recovery. Of note, as botulinum toxin injection is one of the most popular and effective pharmacological methods for treating spasticity, studies comparing the effects of ESWT and botulinum toxin injections, and studies reporting the results of their combination, are also reviewed in this paper.

Transrectal ultrasound-guided transperineal botulinum toxin a injection to the external urethral sphincter for treatment of detrusor external sphincter dyssynergia in patients with spinal cord injury.

OBJECTIVE: To evaluate the effects of a single transrectal ultrasound (TRUS)-guided transperineal injection of botulinum toxin A (BTX-A) to the external urethral sphincter (EUS) for treating detrusor external sphincter dyssynergia (DESD). DESIGN: Descriptive study. SETTING: Rehabilitation hospital affiliated with a medical university. PARTICIPANTS: Patients (N=18) with suprasacral spinal cord injury who had DESD confirmed on video-urodynamic study. INTERVENTIONS: A single dose of 100U BTX-A was applied into the EUS via TRUS-guided transperineal route injection. MAIN OUTCOME MEASURES: Maximal detrusor pressure, detrusor leak-point pressure, integrated electromyography (iEMG), maximal pressure on static urethral pressure profilometry, and postvoiding residuals. RESULTS: There were significant reductions in iEMG (P=.008) and static (P=.012) and dynamic urethral pressure (P=.023), but not in detrusor pressure and detrusor leak-point pressure after treatment. Postvoiding residuals also significantly decreased in the first and second month after treatment (P<.012). CONCLUSIONS: TRUS-guided transperineal injection of BTX-A has beneficial effects in treating DESD.

Common data elements for traumatic brain injury: recommendations from the interagency working group on demographics and clinical assessment.

Comparing results across studies in traumatic brain injury (TBI) has been difficult because of the variability in data coding, definitions, and collection procedures. The global aim of the Working Group on Demographics and Clinical Assessment was to develop recommendations on the coding of clinical and demographic variables for TBI studies applicable across the broad spectrum of TBI, and to classify these as core, supplemental, or emerging. The process was consensus driven, with input from experts over a broad range of disciplines. Special consideration was given to military and pediatric TBI. Categorizing clinical elements as core versus supplemental proved difficult, given the great variation in types of studies and their interests. The data elements are contained in modules, which are grouped together in categories. Three levels of detail for coding data elements were developed: basic, intermediate, and advanced, with the greatest level of detail in the advanced version. In every case, the more detailed coding can be collapsed into the basic version. Templates were produced to summarize coding formats, motivation of choices, and recommendations for procedures. Work is ongoing to include more international participation and to provide an electronic data entry format with pull-down menus and automated data checks. This proposed standardization will facilitate comparison of research findings across studies and encourage high-quality meta-analysis of individual patient data.

The War on COVID-19 Pandemic: Role of Rehabilitation Professionals and Hospitals.

The global outbreak of coronavirus disease 2019 has created an unprecedented challenge to the society. Currently, the United States stands as the most affected country, and the entire healthcare system is affected, from emergency department, intensive care unit, postacute care, outpatient, to home care. Considering the debility, neurological, pulmonary, neuromuscular, and cognitive complications, rehabilitation professionals can play an important role in the recovery process for individuals with coronavirus disease 2019. Clinicians across the nation's rehabilitation system have already begun working to initiate intensive care unit-based rehabilitation care and develop programs, settings, and specialized care to meet the short- and long-term needs of these individuals. We describe the anticipated rehabilitation demands and the strategies to meet the needs of this population. The complications from coronavirus disease 2019 can be reduced by (1) delivering interdisciplinary rehabilitation that is initiated early and continued throughout the acute hospital stay, (2) providing patient/family education for self-care after discharge from inpatient rehabilitation at either acute or subacute settings, and (3) continuing rehabilitation care in the outpatient setting and at home through ongoing therapy either in-person or via telehealth.

Design and Implementation of a Musculoskeletal Ultrasound Curriculum for Physical Medicine and Rehabilitation Residents: Pilot Data on Improvement of Palpation Accuracy in Physical Examination.

Studies have shown that physical medicine and rehabilitation residents have poor surface anatomy palpation accuracy, suggesting that new methods of teaching musculoskeletal (MSK) examination need to be found. This study describes the design of a novel MSK ultrasound course that integrated ultrasonography skills with palpation skills. Ultrasound was used to teach, validate, and refine physical medicine and rehabilitation residents' palpation of MSK structures. Surface anatomy palpation is intimately related to ultrasonography as clinicians should use palpation to guide their ultrasound examination rather than purely follow an algorithm. This study assessed whether the ultrasound course improved physical medicine and rehabilitation resident palpation accuracy at 12 upper limb structures. Palpation accuracy was tested at the beginning of their residency training and retested several weeks after completion of the ultrasound course's upper limb component, to assess retention of skill. There was significant improvement (P < 0.05) in 9 of 12 sites from pretesting to posttesting. Mean postcourse palpation accuracy was within 1 cm for 8 of 12 structures. This study demonstrates that an integrated MSK ultrasound and palpation curriculum improves palpation accuracy at multiple MSK structures and this improvement is retained. Physical medicine and rehabilitation residencies should consider integrating palpation skills into their ultrasound curriculum to improve the caliber of their trainees.

Clinical Tests of the Shoulder: Accuracy and Extension Using Dynamic Ultrasound.

Shoulder pain is a common musculoskeletal disorder that has a significant impact on the patient's quality of life and functional health. Because the shoulder joint is a complex structure, the relevant symptoms of shoulder pain may not directly reflect the underlying pathology. Hence, several shoulder tests have been developed to examine shoulder problems, and their diagnostic accuracy varies. Familiarization with the performance of those physical tests and their strength and limitation are of utmost importance for physicians dealing with shoulder disorders. Therefore, the present narrative review focuses on summarizing the most commonly used tests in physical examination and their diagnostic performance on several shoulder pathologies. This article also discusses how ultrasound imaging can serve as an extension of those tests.

Identifying and Monitoring Deficiencies in Physical Examination of the Foot and Ankle With Diagnostic Ultrasound: Experience From a Physical Medicine and Rehabilitation Residency Training Program.

Despite the high incidence of foot and ankle injuries and their biomechanical importance to more proximal joints, the foot and ankle are some of the most daunting and underemphasized musculoskeletal structures in medical training. This study used musculoskeletal ultrasound to identify a knowledge gap in physical medicine and rehabilitation residents in foot and ankle surface anatomy palpation and to determine whether senior residents had higher examination performance compared with more junior residents. Physical medicine and rehabilitation residents at different levels of training were tested cross-sectionally, and palpation accuracy was compared by class year. There was a trend of improvement across class years, with significant class differences in accuracy for the talonavicular joint, calcaneocuboidal joint, and posterior tibialis and peroneal tendons (P < 0.05). Despite this trend, the accuracy was not consistently higher among the senior residents considering the training they received. For all 30 residents assessed, accuracy within 1 cm was highest for the tibiotalar joint (93.3%), peroneal tendons (83.3%), posterior tibialis tendon (63.3%), and talonavicular joint (50%). It was lower for the calcaneocuboidal joint (26.7%) and the second (13.3%) and fourth for the tarsometatarsal joints (20%). Anatomical knowledge and palpation skills of the foot and ankle, particularly at the midfoot and forefoot, may be an area of improvement for physical medicine and rehabilitation resident training.

Social participation in head and neck cancer survivors with swallowing disorder: World Health Organization Disability Assessment Schedule 2.0 study.

BACKGROUND: Social function and quality of life were negatively impacted by the sequelae of treatment for the disease in the head and neck cancer survivor with swallowing disorder. METHOD: Data from a total of 1023 survivors between July 2012 and November 2017 were collected from the Taiwan Data Bank of Persons with Disability. Nonparametric rank F test was used to analyze the influence of different variables on social participation. RESULTS: (a) All WHODAS (World Health Organization Disability Assessment Schedule) 2.0 scores revealed significantly increased difficulty when swallowing impairment increased (P < .001). (b) Unemployment, institutionalization, severity of swallowing impairment, cancer sites, and WHODAS 2.0 score of domains 1 to 4 were negatively related to social participation, while living in rural area is related to increased social participation. CONCLUSIONS: Social participation was negatively affected by many variables in this population. Among these variables, cancer sites and WHODAS 2.0 score of domains 1 to 4 were the strongest factors.

Early-Onset Dementia in War Veterans: Brain Polypathology and Clinicopathologic Complexity.

The neuropathology associated with cognitive decline in military personnel exposed to traumatic brain injury (TBI) and chronic stress is incompletely understood. Few studies have examined clinicopathologic correlations between phosphorylated-tau neurofibrillary tangles, ß-amyloid neuritic plaques, neuroinflammation, or white matter (WM) lesions, and neuropsychiatric disorders in veterans. We describe clinicopathologic findings in 4 military veterans with early-onset dementia (EOD) who had varying histories of blunt- and blast-TBI, cognitive decline, behavioral abnormalities, post-traumatic stress disorder, suicidal ideation, and suicide. We found that pathologic lesions in these military-EOD cases could not be categorized as classic Alzheimer's disease (AD), chronic traumatic encephalopathy, traumatic axonal injury, or other well-characterized clinicopathologic entities. Rather, we observed a mixture of polypathology with unusual patterns compared with pathologies found in AD or other dementias. Also, ultrahigh resolution ex vivo MRI in 2 of these 4 brains revealed unusual patterns of periventricular WM injury. These findings suggest that military-EOD cases are associated with atypical combinations of brain lesions and distribution rarely seen in nonmilitary populations. Future prospective studies that acquire neuropsychiatric data before and after deployments, as well as genetic and environmental exposure data, are needed to further elucidate clinicopathologic correlations in military-EOD.

Transperineal injection of botulinum toxin A for treatment of detrusor sphincter dyssynergia: localization with combined fluoroscopic and electromyographic guidance.

OBJECTIVE: To determine the effectiveness of a combined method for localizing external urethral sphincter for transperineal injection of botulinum toxin A (BTX-A) in the treatment of detrusor sphincter dyssynergia (DSD) in patients with spinal cord injury (SCI). DESIGN: A prospective, open-label trial. SETTING: A rehabilitation hospital affiliated with a medical university. PARTICIPANTS: Eighteen SCI patients with voiding dysfunction resulting from urodynamically confirmed DSD. INTERVENTIONS: 100 units of BTX-A injected transperineally into the external urethral sphincter, which was localized using combined fluoroscopic and electromyographic guidance, using a Foley catheter inserted for visualization of vesicourethral anatomy. MAIN OUTCOME MEASURES: (1) postvoid residual volume, (2) leak point pressure, (3) maximal intravesical pressure, (4) maximal urethral pressure, (5) quality of life measures for urination, quantified by the Quality of Life Index (QLI). RESULTS: Positive clinical outcomes were observed in all 18 patients in this study. The mean reductions in postvoid residual volume, leak point pressure, maximal intravesical pressure, and maximal urethral pressure before and after BTX-A injection were 183ml, 37cm H2O, 45cm H2O, and 92cm H2O, respectively (all P values <.05). The mean QLI significantly improved from -0.68+/-0.27 to 0.66+/-0.19 (P<.01). No significant side effects were noted after injection. The clinical therapeutic effects have shown reductions in occurrence and degree of autonomic dysreflexia, vesicoureteral reflux, hydronephrosis, and urinary tract infection. The bladder management programs also obtained improvements in our patients, either doing intermittent catheterizations less frequently, or resuming spontaneous voiding without indwelling catheters. CONCLUSION: With this combined method for localization of the external urethral sphincter, transperineal injection of BTX-A was safe, accurate, easy to perform, and effective for treatment of DSD in patients with SCI.

The potential utility of driving simulators in the cognitive rehabilitation of combat-returnees with traumatic brain injury.

A large number of Operation Enduring Freedom/Operation Iraqi Freedom returnees are seeking DOD and VA rehabilitative care for war-related traumatic brain injury (TBI). This article reviews evidence on the utility of driving simulators as tools for assessment and training in TBI rehabilitation. Traditionally, cognitive rehabilitation has been shown to improve specific cognitive skills. However, there are few studies and only weak evidence to show that these gains transfer to everyday activities. Theoretically, modern driving simulators may be useful in cognitive rehabilitation because they can systematically present realistic and interesting tasks that approximate driving activities, while automatically monitoring performance. The use of simulation technology for patients with TBI provides cognitive stimulation in an ecologically compatible setting, without the risks associated with a corresponding real-world experience. The utility, limitations, and future directions for the use of driving simulator in the rehabilitation of patients with war-related TBI are discussed.

Hawai'i Concussion Awareness & Management Program (HCAMP): Impact.

Concussion, also referred to as mild traumatic brain injury (mTBI), is caused by a direct or indirect blow to the head or body causing the brain to move rapidly within the skull, resulting in immediate, but temporary, brain dysfunction. Developing awareness and promoting concussion education can reduce the number of short and long-term injuries associated with sports and non-sports related concussions in Hawai'i. The purpose of this study was two-fold: (1) to describe the number of concussions in 67 Hawai'i high school athletic programs using the ImPACT database; and (2) to describe which contact and collision sports had the highest rate of concussions in 67 Hawai'i high schools. This was a retrospective study that described the number of concussions generated across school years 2010-2016, concussion data across 14 contact sports, and athletic exposure rating for the 14 contact sports. Data were analyzed and aggregated from a data-bank associated with the Hawai'i Concussion Awareness and Management program. Findings suggest that for Hawai'i high school student athletes' concussions increased from 2010-2013 with a gradual decrease from 2014-2016, specific sports had higher number of concussions (eg, football), and when evaluating concussion rate per 1000 exposures, girls' judo was the highest. These findings stress the need for continued data collection, monitoring, education/awareness and research that will reduce the number of concussions among student athletes.

Therapeutic use of botulinum toxin type A in treating neck and upper-back pain of myofascial origin: a pilot study.

OBJECTIVE: To determine the efficacy of botulinum toxin type A (BTX-A) in treating neck and upper-back pain of myofascial origin. DESIGN: A randomized, double-blind, placebo-controlled pilot study. SETTING: Outpatient physical medicine and rehabilitation clinic of a university-affiliated tertiary hospital. PARTICIPANTS: A total of 29 subjects enrolled from among 45 screened patients. No subject withdrawal due to serious adverse events occurred. INTERVENTION: Subjects were evaluated at baseline, received a 1-time injection of either BTX-A (treatment group) or saline (control group), and were followed up at 2 weeks and at months 1, 2, 3, 4, and 6. MAIN OUTCOME MEASURES: Visual analog scale (VAS) for pain, the Neck Disability Index (NDI), and the Medical Outcome Study 36-Item Short-Form Health Survey (SF-36). RESULTS: Improvements in the VAS and NDI scores were seen in the treatment group but were not significant when compared with the controls. Statistically significant improvements for the treatment group were seen in the SF-36 bodily pain (at months 2 and 4) and mental health (at month 1) scales but not in the other scales, nor in the summary measures. No serious adverse events were reported. CONCLUSIONS: Trends toward improvements in VAS and NDI scores of the BTX-A group are encouraging, but they were possibly due to a placebo effect and were not statistically significant. The BTX-A subjects, at certain time points, showed statistically significant improvements in the bodily pain and mental health scales of the SF-36 compared with controls. Our study had limited power and population base, but the results could be used to properly power follow-up studies to further investigate this topic.

Urodynamic responses to anal stretch in patients with detrusor sphincter dyssynergia.

OBJECTIVE: To evaluate the urodynamic responses to anal stretch in patients with detrusor sphincter dyssynergia (DSD). DESIGN: Descriptive study. SETTING: Rehabilitation hospital affiliated with a medical university. PARTICIPANTS: Patients (N=36) with suprasacral spinal cord injury who had DSD confirmed on cystometrography. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Detrusor pressure, urethral pressure, and summated electromyogram of external urethral sphincter on cystometrography. RESULTS: The urodynamic responses to anal stretch were evaluated in the first half (time 1, 1-15s) and the second half (time 2, 16-30s) of the evaluation time period. The activity of external urethral sphincter was reduced significantly in both times 1 and 2 (P<0.5). The medians of reduction percentages were 33% and 35% for times 1 and 2, respectively. The change of detrusor pressure was not significant in either time 1 or time 2. CONCLUSIONS: Anal stretch can reduce the activity of external urethral sphincter without significant change in detrusor pressure.

Characteristics and rehabilitation outcomes among patients with blast and other injuries sustained during the Global War on Terror.

OBJECTIVE: To describe characteristics and rehabilitation outcomes among patients who received inpatient rehabilitation for blast and other injuries sustained in Iraq and Afghanistan during the Global War on Terror. DESIGN: Observational study based on chart review and Department of Veterans Affairs (VA) administrative data. SETTING: The 4 VA polytrauma rehabilitation centers (PRCs). PARTICIPANTS: Service members (N=188) admitted to a PRC during the first 4 years of the Global War on Terror for injuries sustained during Operation Iraqi Freedom or Operation Enduring Freedom. INTERVENTION: Multidisciplinary comprehensive rehabilitation program. MAIN OUTCOMES MEASURES: Cognitive and motor FIM instrument gain scores and length of stay (LOS). RESULTS: Most war-injured patients had traumatic brain injury, injuries to several other body systems and organs, and associated pain. Fifty-six percent had blast-related injuries, and the pattern of injuries was unique among those with injuries secondary to blasts. Soft tissue, eye, oral and maxillofacial, otologic, penetrating brain injuries, symptoms of post-traumatic stress disorder, and auditory impairments were more common in blast-injured patients than in those with war injuries of other etiologies. The mechanism of the injury did not predict functional outcomes. LOS was variable, particularly for those with blast injuries. Patients with low levels of independence at admissions made the most progress but remained more dependent at discharge compared with other PRC patients. The rate of gain was slower in this low-functioning group. CONCLUSIONS: Blasts produce a unique constellation of injuries but do not make a unique contribution to functional gain scores. Findings underscore the need for assessment and treatment of pain and mental health problems among patients with polytrauma and blast-related injuries. Patients with polytrauma have lifelong needs, and future research should examine needs over time after community re-entry.