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Haider MN, Cole WR, Willer BS, McCulloch K, Horn EC, Bertz PE, Ramsey C, Leddy JJ. Early targeted heart rate exercise is safe and May hasten return-to-duty in service members with acute concussion, a preliminary study. Brain Inj 2024; 38:119-125. [PMID: 38329063 DOI: 10.1080/02699052.2024.2306334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 01/12/2024] [Indexed: 02/09/2024]
Abstract
OBJECTIVE To evaluate the feasibility of an exercise tolerance assessment and intervention added to the Progressive Return to Activity Clinical Recommendations (PRA-CR) in acutely concussed service members (SMs). METHODS This non-randomized, pilot trial was performed at one center. SMs in the experimental group (ERG) performed the Buffalo Concussion March-in-place Test (BCMT) at every clinic visit and were prescribed at least 20 minutes/day of targeted exercise in addition to PRA-CR. Data for the control group (SCG) were extracted from the same clinic immediately prior to ERG. SMs in both groups were assessed by the same clinician to determine return-to-duty. RESULTS BCMT identified concussion-related exercise intolerance in 100% (n = 14) at screening visit (mean 3.4 days after injury) and in 0% (n = 7) who had recovered. No adverse effects were associated with BCMT. The estimated recovery time for ERG who performed the exercise intervention (n = 12) was 17.0 (12.8, 21.2) days and for SCG (n = 15) was 23.7 (19.9, 27.5) days (p = 0.039). CONCLUSION Assessment of exercise tolerance was feasible and could be incorporated into the PRA-CR. Future definitive, randomized controlled trials should be performed to assess the effectiveness of exercise reset program for SMs after concussion.
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Affiliation(s)
- Mohammad Nadir Haider
- Department of Orthopedics, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
| | - Wesley R Cole
- Department of Exercise and Sport Science, Matthew Gfeller Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Barry S Willer
- Department of Psychiatry, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
| | - Karen McCulloch
- Division of Physical Therapy and Curriculum in Human Movement Science, Department of Allied Health Sciences, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Emily C Horn
- UBMD Pediatric, Division of Neonatology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
| | - Patrick E Bertz
- Department of Exercise and Sport Science, Matthew Gfeller Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Crystal Ramsey
- Division of Physical Therapy and Curriculum in Human Movement Science, Department of Allied Health Sciences, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - John J Leddy
- Department of Orthopedics, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
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Remigio-Baker RA, Bailie JM, Ettenhofer ML, Cordero E, Hungerford LD. The Impact of Lifetime Traumatic Brain Injury (TBI) on Mental Health Symptoms among Service Members in Interdisciplinary TBI Programs. Mil Med 2023; 188:199-207. [PMID: 37948227 DOI: 10.1093/milmed/usad085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/14/2023] [Accepted: 05/04/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION Traumatic brain injury (TBI) is highly prevalent among active duty service members (ADSMs) and imposes a significant health burden, particularly on mental health (e.g., post-traumatic stress disorder [PTSD] and depressive symptoms). Little is known about how TBI setting characteristics impact PTSD and depressive symptom expression in service members undergoing interdisciplinary TBI care. MATERIALS AND METHODS The study included 455 patients enrolled in interdisciplinary, outpatient TBI programs within the military health system. Using Poisson regression with robust error variance, TBI injury setting characteristics (i.e., before military service, during military training, and during noncombat/combat deployment) were evaluated against clinically-elevated PTSD (PTSD Checklist, DSM-5 score ≥ 33) and depressive (Patient Health Questionnaire-8 score ≥ 15) symptoms. RESULTS In adjusted models, TBI sustained before military service was associated with less likelihood for clinically-elevated PTSD symptoms at pretreatment (prevalence ratio [PR] = 0.76, confidence interval [CI] = 0.60-0.96) and post-treatment (PR = 0.67, CI = 0.52-0.87). TBI sustained during combat deployment, however, resulted in the greatest impact on clinically-elevated pretreatment PTSD (PR = 1.49, CI = 1.16-1.91) and depressive (PR = 1.47, CI = 1.06-2.03) symptoms. Null results were found between military training/noncombat deployment and mental health symptoms. Regardless of the TBI setting, following TBI treatment, there remained 37.5% (n = 180) and 24.8% (n = 108) with clinically-elevated PTSD and depressive symptoms, respectively. CONCLUSIONS There was a differential impact of TBI settings, particularly between TBI sustained before military service and that from combat deployment among ADSMs enrolled in outpatient TBI programs. This may be indicative of differences in the characteristics of these environments (e.g., injury severity) or the impact of such an event during recovery from current TBIs. The large percentage of ADSMs who present with clinically-elevated mental health symptoms after treatment may suggest the need for additional resources to address mental health needs before, during, and after treatment in TBI programs.
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Affiliation(s)
- Rosemay A Remigio-Baker
- Traumatic Brain Injury Center of Excellence (TBICoE), Silver Spring Metro Center I, Silver Spring, MD 20910, USA
- Compass Government Solutions, Annapolis, MD 21401, USA
| | - Jason M Bailie
- Traumatic Brain Injury Center of Excellence (TBICoE), Silver Spring Metro Center I, Silver Spring, MD 20910, USA
- General Dynamics Information Technology, Falls Church, VA 22042, USA
- Naval Hospital Camp Pendleton, Camp Pendleton, CA 92055, USA
| | - Mark L Ettenhofer
- Traumatic Brain Injury Center of Excellence (TBICoE), Silver Spring Metro Center I, Silver Spring, MD 20910, USA
- General Dynamics Information Technology, Falls Church, VA 22042, USA
- Naval Medical Center of San Diego, 34800 Bob Wilson Dr, San Diego, CA 92134, USA
- University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA
| | - Evelyn Cordero
- Traumatic Brain Injury Center of Excellence (TBICoE), Silver Spring Metro Center I, Silver Spring, MD 20910, USA
- General Dynamics Information Technology, Falls Church, VA 22042, USA
- Naval Hospital Camp Pendleton, Camp Pendleton, CA 92055, USA
| | - Lars D Hungerford
- Traumatic Brain Injury Center of Excellence (TBICoE), Silver Spring Metro Center I, Silver Spring, MD 20910, USA
- General Dynamics Information Technology, Falls Church, VA 22042, USA
- Naval Medical Center of San Diego, 34800 Bob Wilson Dr, San Diego, CA 92134, USA
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Lempke LB, Ermer E, Boltz AJ, Caccese J, Buckley TA, Cameron KL, Chrisman SPD, D'Lauro C, Eckner JT, Esopenko C, Hunt TN, Jain D, Kelly LA, Memmini AK, Mozel AE, Putukian M, Susmarski A, Pasquina PF, McCrea MA, McAllister TW, Broglio SP, Master CL. Initial Mild Traumatic Brain Injury Characteristics and Recovery Patterns Among Females Across the United States Military Service Academies: A Report from the NCAA-DoD CARE Consortium. Ann Biomed Eng 2023:10.1007/s10439-023-03374-z. [PMID: 37743459 DOI: 10.1007/s10439-023-03374-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 09/15/2023] [Indexed: 09/26/2023]
Abstract
Mild traumatic brain injury (mTBI) has been described in the United States (US) military service academy cadet population, but female-specific characteristics and recovery outcomes are poorly characterized despite sex being a confounder. Our objective was to describe female cadets' initial characteristics, assessment performance, and return-to-activity outcomes post-mTBI. Female cadets (n = 472) from the four US military service academies who experienced a mTBI completed standardized mTBI assessments from pre-injury to acute initial injury and unrestricted return-to-duty (uRTD). Initial injury presentation characteristics (e.g., delayed symptoms, retrograde amnesia) and return-to-activity outcomes [i.e., return-to-learn, initiate return-to-duty protocol (iRTD), uRTD] were documented. Descriptive statistics summarized female cadets' injury characteristics, return-to-activity outcomes, and post-mTBI assessment performance change categorization (worsened, unchanged, improved) relative to pre-injury baseline using established change score confidence rank criteria for each assessment score. The median (interquartile range) days to return-to-learn (n = 157) was 7.0 (3.0-14.0), to iRTD (n = 412) was 14.7 (8.6-25.8), and to uRTD (n = 431) was 26.0 (17.7-41.8). The majority experienced worse SCAT total symptom severity (77.8%) and ImPACT reaction time (97.0%) acutely < 24-h versus baseline, but unchanged BESS total errors (75.2%), SAC total score (72%), BSI-18 total score (69.6%), and ImPACT verbal memory (62.3%), visual memory (58.4%), and visual motor speed (52.5%). We observed similar return-to-activity times in the present female cadet cohort relative to the existing female-specific literature. Confidence ranks categorizing post-mTBI performance were heterogenous and indicate multimodal assessments are necessary. Our findings provide clinically relevant insights to female cadets experiencing mTBI across the US service academies for stakeholders providing healthcare.
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Affiliation(s)
- Landon B Lempke
- Michigan Concussion Center, University of Michigan, Ann Arbor, MI, USA.
- Exercise and Sport Science Initiative, University of Michigan, Ann Arbor, MI, USA.
- , 830 North University Avenue, Suite 4000, Ann Arbor, MI, 48109, USA.
| | - Elsa Ermer
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Adrian J Boltz
- Michigan Concussion Center, University of Michigan, Ann Arbor, MI, USA
| | - Jaclyn Caccese
- School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH, USA
| | - Thomas A Buckley
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, USA
| | - Kenneth L Cameron
- Keller Army Hospital and United States Military Academy, West Point, NY, USA
| | - Sara P D Chrisman
- Division of Adolescent Medicine, University of Washington, Seattle, WA, USA
| | - Christopher D'Lauro
- Department of Behavioral Science and Leadership, United States Air Force Academy, USAF Academy, El Paso County, CO, USA
| | - James T Eckner
- Department of Physical Medicine & Rehabilitation, University of Michigan, Ann Arbor, MI, USA
| | - Carrie Esopenko
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Tamerah N Hunt
- Department of Health Sciences and Kinesiology, Georgia Southern University, Statesboro, GA, USA
| | - Divya Jain
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Louise A Kelly
- Department of Exercise Science, California Lutheran University, Thousand Oaks, CA, USA
| | - Allyssa K Memmini
- Department of Health, Exercise & Sports Sciences, University of New Mexico, Albuquerque, NM, USA
| | - Anne E Mozel
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Adam Susmarski
- Department of Orthopedics and Sports Medicine, United States Naval Academy, Annapolis, MD, USA
| | - Paul F Pasquina
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Michael A McCrea
- Center for Neurotrauma Research, Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Thomas W McAllister
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Steven P Broglio
- Michigan Concussion Center, University of Michigan, Ann Arbor, MI, USA
| | - Christina L Master
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Orthopaedics and Sports Medicine, Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Designing research on concussion treatment in the military setting: Important challenges to consider. Prev Med Rep 2022; 24:101603. [PMID: 34976660 PMCID: PMC8683939 DOI: 10.1016/j.pmedr.2021.101603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 10/06/2021] [Accepted: 10/17/2021] [Indexed: 11/24/2022] Open
Abstract
Traumatic brain injury (TBI) is highly prevalent on a global scale with concussion being the most common of all TBIs. Concussion research on rehabilitation and symptom resolution is well-established, particularly among athletes, but less is known about the recovery of active duty service members (ADSMs). In a population whose occupational environment increases risk for such injury, it is imperative that treatment is optimized to achieve successful rehabilitation. The military setting, however, has challenges that must be accounted for when developing proposals to study the benefits of new interventions or treatment. This review will provide a discussion on those challenges to better understand the considerations that are essential during the developmental phase of concussion studies within the military setting. This review aims to provide investigators novice to the military setting an overview of considerations when researching concussion among ADSMs.
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Ettenhofer ML, Remigio-Baker RA, Bailie JM, Cole WR, Gregory E. Best Practices for Progressive Return to Activity after Concussion: Lessons Learned from a Prospective Study of U.S. Military Service Members. Neurotrauma Rep 2020; 1:137-145. [PMID: 33274343 PMCID: PMC7703689 DOI: 10.1089/neur.2020.0023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Primary care providers can play a crucial role in the clinical management of concussion. However, many providers lack up-to-date information about best practices for rest and return to activity after these injuries. Most research on this topic has been conducted in athletes, and so less is known about how to assist patients with returning to activity in other settings and populations. This article provides a review of best practices for management of progressive return to activity after concussion, with an emphasis on "lessons learned" from the Defense and Veterans Brain Injury Center (DVBIC) Progressive Return to Activity (PRA) study, a multi-site longitudinal research project conducted to evaluate concussion management practices and the effectiveness of provider training on DVBIC clinical recommendations (CRs). Provider clinical practices and patient outcomes were examined at three U.S. military treatment facilities before and after providers completed a standardized training on DVBIC PRA CRs. In summary, research findings provide additional support that concussion recovery can be influenced by patients' activity levels after injury. Patients with concussion may experience poorer outcomes if they return to pre-injury levels of activity too rapidly, but they may also be at risk for prolonged symptoms if they fail to increase activity levels over time after an initial period of rest. Additionally, training primary care providers in return to activity guidelines can result in more effective patient education and better clinical outcomes. This knowledge can be used to inform best practices for progressive return to activity in both civilian and military settings.
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Affiliation(s)
- Mark L. Ettenhofer
- Defense and Veterans Brain Injury Center, Silver Spring, Maryland, USA
- Naval Medical Center San Diego, San Diego, California, USA
- General Dynamics Information Technology, Fairfax, Virginia, USA
- University of California, San Diego, La Jolla, California, USA
| | - Rosemay A. Remigio-Baker
- Defense and Veterans Brain Injury Center, Silver Spring, Maryland, USA
- Naval Hospital Camp Pendleton, Camp Pendleton, California, USA
- Henry M. Jackson Foundation, Bethesda, Maryland, USA
| | - Jason M. Bailie
- Defense and Veterans Brain Injury Center, Silver Spring, Maryland, USA
- General Dynamics Information Technology, Fairfax, Virginia, USA
- Naval Hospital Camp Pendleton, Camp Pendleton, California, USA
| | - Wesley R. Cole
- Defense and Veterans Brain Injury Center, Silver Spring, Maryland, USA
- Womack Army Medical Center, Fort Bragg, North Carolina, USA
| | - Emma Gregory
- Defense and Veterans Brain Injury Center, Silver Spring, Maryland, USA
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Register-Mihalik JK, Callahan CE. Postconcussion Exertion Evolution: Clinical and Behavioral Considerations. Curr Sports Med Rep 2020; 19:151-156. [PMID: 32282461 DOI: 10.1249/jsr.0000000000000703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The philosophy and practices concerning concussion management have evolved from passive to active strategies that incorporate immediate, guided rest followed by early integration of physical and cognitive activity as tolerated by symptoms. Recent research and clinical evidence support guidance that symptom tolerable and clinically guided activity is beneficial postconcussion both acutely and in the longer term. Furthermore, recent studies illustrate benefits of targeted deficit-based therapies (vestibular, cervicogenic, visual, psychological, etc.) postconcussion subacutely and in those with persistent symptoms. The dissemination of this new information occurs at a fast pace and is often difficult to rapidly integrate into clinical practice due to necessary policy and behavior changes. This review will outline recent evidence concerning both rest and exertion postconcussion through the lens of the socioecological model to more rapidly promote policy and practice changes.
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