Physical activity after mild traumatic brain injury: What are the relationships with fatigue and sleep quality?

Fatigue in young patients with acquired brain injury in the outpatient rehabilitation setting: A 2-year follow-up study

Acquired brain injury (ABI) may cause fatigue and participation restrictions in young patients. However, knowledge regarding the course of these problems over time is lacking. This study aims to describe the course of fatigue and participation and their relationship over time in an observational two-year follow-up study among patients(5-24 years) with ABI referred for outpatient rehabilitation and their parents. Patients/parents completed the PedsQL™Multidimensional-Fatigue-Scale(PedsQL™MFS, totalscore/3-domains) and the Child/Adolescent-Scale of Participation(CASP, totalscore/4-domains). Scores ranged from 0-100: lower scores = more fatigue/participation problems. Linear mixed models and repeated measures correlations were used to determine the course over time (change-scores/95%CI) and correlations between fatigue/participation. At baseline, 223 patients/246 parents participated with 94/104 at either T1, T2 or both. Median age was 15 years (IQR:12-17), 74% had a traumatic brain injury. Mean(SD) patient/parent-reported PedsQL™MFS totalscores(baseline) were: 50.3(17.3) and 53.8(19.1), respectively. CASP totalscores were 78.0(16.4) and 87.1(13.6). Over time, patient-reported scores improved significantly (fatigue: + 8.8 (2.9;14.7), p < 0.05)/participation: + 10.5 (6.3;14.7), p < 0.05)). Similar results were found regarding parent-reported fatigue: + 8.7 (3.4;13.9), p < 0.05 but not regarding participation. Two years later, fatigue was still considerable(patients:59.1/parents:62.5). Moderate/fair correlations between fatigue/participation over time were found. Fatigue and participation in young patients with ABI improved two years after referral to rehabilitation. However, fatigue remained a considerable problem.

Associations between health-related behaviors and self-reported cognitive symptoms in U.S. military personnel injured on deployment

Health behaviors may be core contributors to cognition and mental health following mild traumatic brain injury (TBI). The aims of the present study examined: (1) whether health behaviors including sleep duration, alcohol use, and physical activity differed in injured military personnel with and without deployment-related mild TBI history and (2) the relative contributions of health behaviors and deployment-related mild TBI history to self-reported cognitive, posttraumatic stress disorder (PTSD), and depressive symptoms. Participants included 3076 military personnel injured on deployment participating in the Wounded Warrior Recovery Project, an ongoing web-based study. Military personnel with deployment-related mild TBI history reported similar rates of physical activity and levels of alcohol problems as those without, but were less likely to report receiving the recommended duration of sleep. When adjusting for demographic and injury variables, all three health behaviors were associated with cognitive, PTSD, and depressive symptoms. Alcohol problems demonstrated significant but small effects across all outcomes measures (ηp2=.01) whereas physical activity was associated with slightly larger effects albeit still within the small range (ηp2=.02-0.04). Duration of sleep bordered a medium effect for cognitive symptoms (ηp2=.05) and was in the medium range for PTSD and depressive symptoms (ηp2=.06). Although deployment-related mild TBI history was significant in all models, effect sizes were small (ηp2=.01). Findings from the present study provide support that health behaviors have stronger effects with regard to cognitive, PTSD, and depressive symptoms compared to deployment-related mild TBI history in military personnel and, given their modifiable nature, may represent treatment targets in this population.

Effectiveness of exercise in improving quality of life in patients with traumatic brain injury: A systematic review and meta-analysis

BACKGROUND

Traumatic brain injury (TBI) is a major cause of disability and mortality worldwide. People with TBI exhibit poor quality of life (QOL). Exercise is considered a possible intervention for improving cognitive function and mood, helping improve QOL in patients with TBI. According to our review of the relevant literature, meta-analyses have yet to explore the effect of exercise on QOL in patients with TBI.

OBJECTIVES

To determine by meta-analysis of relevant studies whether physical exercise could promote QOL in patients with TBI.

METHODS

A systematic review and meta-analysis of intervention studies involving physical exercise for improving QOL outcomes in TBI populations were conducted according to the PRISMA guideline. Our inclusion criteria were as follows: being randomized or nonrandomized controlled trials with quantitative designs that included patients diagnosed with TBI.

RESULTS

Thus, six studies met the inclusion criteria. The interventions in four of the six studies had statistically significant effects on QOL improvement. Our meta-analysis revealed a moderate effect size of physical exercise on QOL promotion in patients with TBI.

CONCLUSION

For TBI, exercise seems to improve QOL. More research with long-term follow-up should be conducted to assess the effect of exercise on patients with TBI.

The prevalence and impact of orthostatic intolerance in young women across the hypermobility spectrum

Orthostatic intolerance (OI) is frequently reported in young women with generalized hypermobility spectrum disorder (G-HSD) and hypermobile EDS (hEDS). However, it remains currently unclear whether OI is a comorbidity or fundamental part of the pathophysiology of G-HSD or hEDS. This study investigated the prevalence and impact of OI in young women across the hypermobility spectrum. Forty-five women (14-30 years, 15 controls, 15 G-HSD, and 15 hEDS) undertook a head-up tilt (HUT) and active stand test. Postural Orthostatic Tachycardia Syndrome (POTS) and Orthostatic Hypotension (OH) were assessed using age-related criteria. Autonomic dysfunction and quality-of-life questionnaires were also completed. The prevalence of POTS was higher in women with G-HSD than hEDS and control groups during HUT (43% vs. 7% and 7%, respectively, p < 0.05), but similar between groups during the active stand (47%, 27%, and 13% for G-HSD, hEDS, and control, respectively). No participants had OH. hEDS and G-HSD participants reported more severe orthostatic symptoms and poorer quality of life than controls. Although POTS was observed in hypermobile participants, there is no conclusive evidence that its prevalence differed between groups due to differences between the HUT and active stand assessments. Nevertheless, OI and broader autonomic dysfunction impacted on their quality of life.

Application of Second-Order Growth Mixture Modeling (SO-GMM) to Longitudinal TBI Outcome Research: 15-year Trajectories of Life Satisfaction in Adolescents and Young Adults (AYA) as an Example

OBJECTIVE

To demonstrate the application of Second-Order Growth Mixture Modeling using life satisfaction among adolescents and young adults with TBI up to 15 years post-injury.

DESIGN

SO-GMM, a data-driven modeling approach that accounts for measurement errors, was adopted to uncover distinct growth trajectories of life satisfaction over 15 years post-injury. Membership in growth trajectories was then linked with baseline characteristics to understand the contributing factors to distinct growth over time.

SETTING

Traumatic Brain Injury Model System National Database PARTICIPANTS: 3,756 AYAs with TBI aged 16 - 25 (M_age=20.49, SD_age=2.66; 27.24% female) INTERVENTIONS: Not Applicable MAIN OUTCOME MEASURES: Satisfaction with Life Scale RESULTS: Four quadratic growth trajectories were identified: low-stable (16.6%) that had low initial life satisfaction and remained low over time; high-stable (49.3%) that had high life satisfaction at the baseline and stayed high over time; high-decreasing (15.8%) that started with high life satisfaction but decreased over time; and low-increasing (18.2%) that started with low life satisfaction but increased over time. Sex, race, pre-injury employment status, age, and FIM cognition were associated with group assignment.

CONCLUSION

This study applied SO-GMM to a national TBI database and identified four longitudinal trajectories of life satisfaction among AYAs with TBI. Findings provided data-driven evidence for development of future interventions that are tailored at both temporal and personalized levels for improved health outcomes among AYAs with TBI.

Sleep quality in the chronic stage of concussion is associated with poorer recovery: A systematic review

Background

Recovery from a concussion varies based on a multitude of factors. One such factor is sleep disturbances. In our prior review, it was observed that in the acute phase, sleep disturbances are predictive of poor outcomes following a concussion. The literature gap remains on how sleep in the chronic phase of recovery affects outcomes.

Objective

To examine the association between sleep quality during the chronic stage of concussion and post-concussion outcomes. Literature Survey: Literature searches were performed during 1 July to 1 August 2019 in selected databases along with searching grey literature. Out of the 733 results, 702 references were reviewed after duplicate removal.

Methods

Three reviewers independently reviewed and consented on abstracts meeting eligibility criteria ( n = 35). The full-text articles were assessed independently by two reviewers. Consensus was achieved, leaving four articles. Relevant data from each study was extracted using a standard data-extraction table. Quality appraisal was conducted to assess potential bias and the quality of articles.

Results

One study included children (18–60 months) and three studies included adolescents and/or adults (ranging 12–35 years). The association between sleep and cognition (two studies), physical activity (one study), and emotion symptoms (one study) was examined. Sleep quality was associated with decreased cognition and emotional symptoms, but not with meeting physical activity guidelines six months post-concussion injury.

Conclusions

The heterogeneity in age of participants and outcomes across studies and limited number of included studies made interpretations difficult. Future studies may consider if addressing sleep quality following concussion will improve outcomes.

From Provider to Advocate: The Complexities of Traumatic Brain Injury Prompt the Evolution of Provider Engagement

Treating a patient with traumatic brain injury requires an interdisciplinary approach because of the pervasive, profound and protean manifestations of this condition. In this review, key aspects of the medical history and review of systems will be described in order to highlight how the role of any provider must evolve to become a better patient advocate. Although this review is written from the vantage point of a vision care provider, it is hoped that patients, caregivers and providers will recognize the need for a team approach.

Characterizing Physical Activity and Sedentary Behavior in Adults With Persistent Postconcussive Symptoms After Mild Traumatic Brain Injury

OBJECTIVE

To evaluate physical activity (PA) and sedentary behavior and their associations with symptom and quality of life outcomes in adults with persistent postconcussive symptoms (PPCS) after mild traumatic brain injury (mTBI).

DESIGN

Cross-sectional cohort study.

SETTING

Outpatient brain injury clinic.

PARTICIPANTS

Consecutive sample of adults (N=180) with a diagnosis of mTBI and PPCS.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

PA and sedentary behavior were assessed using the Godin Leisure-Time Exercise Questionnaire and Rapid Assessment Disuse Index, respectively. Participants were dichotomized according to whether they completed 150 minutes of moderate-to-vigorous PA per week, based on Canadian guidelines. Postinjury moderate-to-vigorous PA was also analyzed as a continuous variable.

RESULTS

Prior to injury, 85% of participants reported meeting PA guidelines, compared with 28% postinjury. Individuals meeting PA guidelines postinjury reported higher quality of life (η²_p=0.130; P<.001) and lower scores on measures of functional impact of headache (η²_p=0.065; P=.009), fatigue (η²_p=0.080; P=.004), depression (η²_p=0.085; P=.001), and anxiety (η²_p=0.046; P=.031), compared with those not meeting guidelines. Sedentary behavior postinjury was negatively correlated with quality of life (r_s[127]=-0.252; P=.004) and positively correlated with symptom burden (r_s[167]=0.227; P=.003), fatigue (r_s[127]=0.288; P=.001), depression (r_s[174]=0.319; P<.001), and anxiety (r_s[127]=0.180; P=.042).

CONCLUSIONS

PA was significantly decreased in individuals with PPCS compared to preinjury levels. Meeting PA guidelines postinjury was associated with better clinical outcomes, suggesting that returning individuals to PA should be considered in the treatment of this patient population.

Assessment and Treatment of Concussion in the Pediatric Population

Traumatic brain injury (TBI) is common in children. The evaluation and management of children with TBI is based on the research performed in adults. There is a relative paucity of research in the literature involving children and many of the practice recommendations for this age are based on expert opinion in the absence of good research studies in both sports and non-sports-related injuries. The pediatric population is heterogeneous and the approach might be specific for infants, preschoolers, school age children, and adolescents. Children may also suffer from neurodevelopmental disabilities, making their evaluation even more challenging. Adult neurologists are often asked to see children due to increasing demands. This review will focus on specific issues related to TBI in children that might be useful to adult neurologists. Science, however, is evolving rapidly and physicians should make sure to remain up to date to offer evidence-based services to their patients.

Effects of Interval-Training Exercise on People Who Have Had Persistent Post-Concussive Symptoms for Less Than One Year: A Pilot Study

This study is to examine the effects of a 12-session moderate intensity-interval-training program with blood flow restriction (BFR) and body cooling (BC) on people who have had persistent post-concussive symptoms (PPCS) for <1 year. A single-blind randomized controlled trial of interval-training exercise with BFR and BC was conducted. Twenty-five adults with PPCS were assigned to the experimental group (n = 14) or the control group (n = 11). Both groups rode a recumbent elliptical machine for 21 min at moderate intensity (65% predicted maximum heart rate) twice a week for 6 weeks, but only the experimental group received BFR and BC while riding. The variances of overall PPCS scale scores and their sub-domain scores for individuals during the 6-week intervention and 6-week follow-up period were calculated. During the intervention, the fluctuation of overall symptom severity, severity in the cognitive domain and severity in the mood domain were significantly less in the experimental group (p = 0.03; p = 0.02; p = 0.02). During the follow-up period, the number of symptoms remained more stable in the experimental group (p = 0.02), and a trend toward less fluctuation of symptom severity (p = 0.05) was also observed. The reduced number of symptoms in the cognitive and sleep domains remained more stable in the experimental group following the intervention (p = 0.007; p = 0.02). The severity of mood and sleep symptoms also remained more stable during the follow-up period in the experimental group (p = 0.04). More stable recovery was found in individuals who exercised using BFR and BC than in those who underwent exercise without BFR and BC. Moderate intensity-interval-training exercise with BFR and BC alleviated post-concussive symptoms in people who have had PPCS <1 year.