Recruiting for a multicentre DoD and VA longitudinal study: lessons learned

PRIMARY OBJECTIVE

The primary objective of the study is to identify and delineate effective recruitment practises in a large, multi-site, longitudinal, observational study employing both military service members and Veterans.

SETTING

Four Chronic Effects of Neurotrauma Consortium sites.

DESIGN

A descriptive study.

RESULTS

Overall and cohort-specific recruitment increased with the addition of focused recruitment strategies and a military/Veteran-centric recruitment director.

CONCLUSION

Use of site-specific strategies aligned with local Institutional Review Board procedures and emphasizing awareness of service member organizational allegiances was the key to effective recruiting. Adding a recruitment director with background similar to study participants coincided with significantly improved overall participant numbers and specific subpopulations of research subjects, thus adding to the value of the study.

Chronic Effects of Neurotrauma Consortium (CENC) multicentre study interim analysis: Differences between participants with positive versus negative mild TBI histories

OBJECTIVES

Compare characteristics and outcomes of combat-exposed military personnel with positive versus negative mild traumatic brain injury (mTBI) histories.

SETTING

Recruitment was from registration lists and ambulatory clinics at four veterans administration hospitals.

PARTICIPANTS

Consented veterans and service members completing initial evaluation by September 2016 (n = 492).

DESIGN

Observational with cross-sectional analyses.

MAIN MEASURES

Multimodal assessments including structured interviews, record review, questionnaires, neuroendocrine labs and neurocognitive and sensorimotor performance.

RESULTS

In unadjusted comparisons to those absent lifetime mTBI, the mTBI positive group (84%) had greater combat exposure, more potential concussive events, less social support and more comorbidities, including asthma, sleeping problems and post-traumatic stress disorder. They also fared worse on all sensory and pain symptom scores and self-reported functional and global outcomes. They had poorer scores on Wechsler Adult Intelligence Scale-IV coding (processing speed), TMT-B (visual-motor integration and executive function) and two posturography subtests, but were otherwise equal to TBI negative participants on neurocognitive and sensorimotor testing and neuroendocrine levels.

CONCLUSIONS

Although differences in characteristics exist which were not adjusted for, participants with historical mTBI have greater symptomatology and life functioning difficulties compared with non-TBI. Performance measures were less dissimilar between groups. These findings will guide further research within this accruing cohort.

Survival of patients with spinal cord injury after cardiac arrest in Department of Veterans Affairs hospital: Pilot study

Survivability characteristics after cardiopulmonary resuscitation in the population with spinal cord injury (SCI) are unclear but may be useful for advanced care planning discussions with patients. Retrospective evaluation from records of all SCI patients over 10 yr at a Department of Veterans Affairs medical center who experienced in-hospital cardiac arrest was performed. Demographic data and other common measurements were recorded. Thirty-six male subjects were identified, and only two patients survived to discharge (5.5% survival rate), both of whom were admitted for nonacute issues and were asymptomatic shortly before the cardiac arrest. The mean age at the time of cardiopulmonary arrest was 62.4 yr, with a mean time from cardiac arrest to death of 3.02 d. No significant demographic parameters were identified. Overall, SCI likely portends worse outcome for acutely ill patients in the situation of a cardiac arrest. Conclusions are limited by sample size.

Effects of hyperbaric oxygen on eye tracking abnormalities in males after mild traumatic brain injury

The effects of hyperbaric oxygen (HBO2) on eye movement abnormalities in 60 military servicemembers with at least one mild traumatic brain injury (TBI) from combat were examined in a single-center, randomized, double-blind, sham-controlled, prospective study at the Naval Medicine Operational Training Center. During the 10 wk of the study, each subject was delivered a series of 40, once a day, hyperbaric chamber compressions at a pressure of 2.0 atmospheres absolute (ATA). At each session, subjects breathed one of three preassigned oxygen fractions (10.5%, 75%, or 100%) for 1 h, resulting in an oxygen exposure equivalent to breathing either surface air, 100% oxygen at 1.5 ATA, or 100% oxygen at 2.0 ATA, respectively. Using a standardized, validated, computerized eye tracking protocol, fixation, saccades, and smooth pursuit eye movements were measured just prior to intervention and immediately postintervention. Between and within groups testing of pre- and postintervention means revealed no significant differences on eye movement abnormalities and no significant main effect for HBO2 at either 1.5 ATA or 2.0 ATA equivalent compared with the sham-control. This study demonstrated that neither 1.5 nor 2.0 ATA equivalent HBO2 had an effect on postconcussive eye movement abnormalities after mild TBI when compared with a sham-control.

The VA/DoD Chronic Effects of Neurotrauma Consortium: An Overview at Year 1

This federally funded program identifies gaps in research and provides support services for scientific, clinical, and translational research projects focused on the long-term effects of mild traumatic brain injury in veterans and active-duty service members.

Elevated liver enzymes following polytraumatic injury

This retrospective cohort study examined the prevalence and potential risk factors for elevated liver enzymes in patients following traumatic brain injury (TBI). The participants were servicemembers with TBI admitted to the Polytrauma Rehabilitation Center (PRC) at the Hunter Holmes McGuire Department of Veterans Affairs Medical Center in Richmond, Virginia, from January 2008 through December 2011. The PRC had 207 patients during this time period, 121 of whom had a liver panel within 30 d of injury. Patients were retrospectively analyzed and placed into one of two categories based on alanine aminotransferase (ALT) values. Of the 121 subjects, 59 (49%) had an ALT of 44 IU/L or greater on their initial set of laboratories. These subjects were compared with those with an ALT of 43 IU/L or less using chi square analysis. There were no significant differences between the two groups with regards to sex, military status, race, theater, TBI mechanism, severity of TBI, or concomitant injuries. Regardless of demographics, mechanism of injury, or extent of trauma, elevated liver enzymes are common in patients admitted to the rehabilitation unit following TBI. For the majority of these patients, enzymes returned to normal with conservative management. In most cases, no specific etiology was ever defined. Further analysis will be performed to determine the most efficient way to monitor these patients so that unnecessary test are avoided and medical expenses are minimized.

Hyperbaric oxygen for blast-related postconcussion syndrome: three-month outcomes

OBJECTIVE

Mild traumatic brain injury (mTBI) and postconcussion syndrome (PCS) are common among military combatants. Hyperbaric oxygen (HBO2 ) is a proposed treatment for these conditions, but it has not been rigorously studied. The objective of this study was to determine the effects of HBO2 by 3 months post compression at 2 commonly employed dosing levels to treat PCS; whether specific subgroups may have benefited; and if no overall effect was found, whether benefit is masked by other conditions.

METHODS

This randomized, double-blind, sham-controlled study was conducted at the Naval Air Station in Pensacola, Florida on 61 male Marines with a history of mTBI and PCS. Intervention consisted of 40 once daily 60-minute hyperbaric chamber compressions at 2.0 atmospheres absolute (ATA) at 1 of 3 randomly preassigned oxygen fractions, resulting in respective blinded groups with an oxygen-breathing exposure equivalent to (1) surface air (sham), (2) 100% oxygen at 1.5ATA, or (3) 100% oxygen at 2.0ATA. The main outcome measure was the Rivermead Post-Concussion Questionnaire-16 (RPQ-16) collected before compressions and at 2 later points.

RESULTS

The interaction of time by intervention group was not significant for improvement on the RPQ-16. Nor was there evidence of efficacy on the RPQ-16 for any subgroup. No significant time by intervention interaction was found for any functional, cognitive, or psychomotor secondary outcome measure at an unadjusted 0.05 significance level.

INTERPRETATION

Using a randomized control trial design and analysis including a sham, results showed no evidence of efficacy by 3 months post-compression to treat the symptomatic, cognitive, or behavioral sequelae of PCS after combat-related mTBI.

The effect of hyperbaric oxygen on symptoms after mild traumatic brain injury

In this single-center, double-blind, randomized, sham-controlled, prospective trial at the U.S. Air Force School of Aerospace Medicine, the effects of 2.4 atmospheres absolute (ATA) hyperbaric oxygen (HBO₂) on post-concussion symptoms in 50 military service members with at least one combat-related, mild traumatic brain injury were examined. Each subject received 30 sessions of either a sham compression (room air at 1.3 ATA) or HBO₂ treatments at 2.4 ATA over an 8-week period. Individual and total symptoms scores on Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT®) and composite scores on Post-traumatic Disorder Check List-Military Version (PCL-M) were measured just prior to intervention and 6 weeks after completion of intervention. Difference testing of post-intervention means between the sham-control and HBO₂ group revealed no significant differences on the PCL-M composite score (t=-0.205, p=0.84) or on the ImPACT total score (t=-0.943, p=0.35), demonstrating no significant effect for HBO₂ at 2.4 ATA. PCL-M composite scores and ImPACT total scores for sham-control and HBO(2) groups revealed significant improvement over the course of the study for both the sham-control group (t=3.76, p=0.001) and the HBO₂ group (t=3.90, p=0.001), demonstrating no significant HBO₂ effect. Paired t-test results revealed 10 ImPACT scale scores in the sham-control group improved from pre- to post-testing, whereas two scale scores significantly improved in the HBO₂ group. One PCL-M measure improved from pre- to post-testing in both groups. This study showed that HBO₂ at 2.4 ATA pressure had no effect on post-concussive symptoms after mild TBI.

Assessment and treatment of common persistent sequelae following blast induced mild traumatic brain injury

The ongoing wars in Iraq and Afghanistan and terrorist activity worldwide have been associated with an increased incidence of blast injuries. While blast injuries share similarities with blunt or penetrating traumatic injuries, there are unique mechanistic elements of blast injury that create increased vulnerability to damage of specific organs. This review highlights the mechanism of blast-related injury, describes the common sequelae of blast exposure that may impact rehabilitation care, and summarizes the intervention strategies for these blast-related sequelae.

Health literacy among patients diagnosed with movement disorders: a pilot study

OBJECTIVE

The study sought to examine the functional health literacy in a sample of geriatric patients diagnosed with movement disorders. The hypothesis was that the study group would demonstrate marginal levels of health literacy scores on a standardized health literacy instrument.

DESIGN/SETTING

The study used a prospective analysis of patients referred to an outpatient movement disorders clinic in a Veterans Affairs Medical Center.

PATIENTS

Fifty-four men with a movement disorder volunteered for the study, with data analysis conducted on 44 of these patients.

MAIN OUTCOME MEASUREMENTS

The primary outcome measure was the Test of Functional Health Literacy in Adults (TOFHLA).

RESULTS

Members of the current sample demonstrated adequate health literacy and scored significantly higher on the TOFHLA relative to the measure's normative sample. Younger age, more education, and higher Mini Mental Status Examination (MMSE) scores were predictive of health literacy.

CONCLUSIONS

The extant literature strongly suggests that limited health literacy is a frequent problem across the United States and represents a considerable obstacle to the effective delivery of health care. In a group of movement disorder subjects with a Folstein MMSE of at least 24, health literacy was generally well preserved. Years with movement disorder and severity of disorder did not impact health literacy. Thus, practitioners should not be prejudiced in a belief that individuals with movement disorders cannot manage their medications.

A pilot study of vitamin D and balance characteristics in middle-aged, healthy individuals

OBJECTIVE

To examine what relationship exists between 25-hydroxyvitamin D (25-OHD) levels and postural competency in the middle-aged, healthy individual.

DESIGN

A community convenience sample.

SETTING

Major medical center employees.

SUBJECTS

Thirty-five healthy individuals older than 40 years of age who demonstrated appropriate cognition and physical stability. Specific exclusion criteria included any prior history of hip, knee, or ankle fracture or surgery.

METHODS

Questionnaire regarding exercise and sun exposure, vitamin D blood level, followed by computerized dynamic posturography (CDP) assessment of balance.

MAIN OUTCOME MEASUREMENTS

CDP scores of individuals with normal and subnormal vitamin D levels.

RESULTS

Thirteen male and 22 female subjects had a mean age of 56.0 years (standard deviation, 7.6; range, 42-77). Self-reported, retrospective mean weekly sun exposure was 7.36 hours (standard deviation, 6.4 hours). Twenty-six subjects (76.5%) described themselves as regular exercisers. Mean 25-OHD level for the sample was 21.5 ng/mL (standard deviation, 12.1 ng/mL). When subjects were divided into those with low and high 25-OHD levels, there was no significant difference in composite limits of stability reaction time scores (mean, 0.98 seconds and 0.84 seconds; P = .23), composite maximal velocity scores (4.2 degrees /second and 5.5 degrees /second; P = .08), composite end point excursion (70.3% and 70.1%; P = .95), and directional control composite scores (71.0% and 71.4%; P = .93). The two groups also showed no significant differences in rhythmic weight shifting left and right as well as forward and backward.

CONCLUSIONS

Unlike studies involving elderly subjects, this study of younger, healthy subjects did not demonstrate a relationship between vitamin D and balance.

Percutaneous sacroplasty for osteoporotic sacral insufficiency fractures: a prospective, multicenter, observational pilot study

BACKGROUND CONTEXT

Sacral insufficiency fractures (SIFs) can cause low back pain in osteoporotic patients. Symptomatic improvement may require up to 12 months. Treatment includes limited weightbearing and bed rest, oral analgesics, and sacral corsets. Significant mortality and morbidity are associated with pelvic insufficiency fractures. Percutaneous injection of polymethylmethacrylate (PMMA) into the fractured ala, sacroplasty, is an alternative treatment for SIF patients. Under fluoroscopic control, 13-G bone trochars are inserted into the fractured ala while the patient is maintained under conscious sedation. Initial reports have documented safe and effective performance of sacroplasty. Yet, these uncontrolled findings do not allow any precision in estimating complication rates or expected outcome.

PURPOSE

Assess rates of complications and observe outcomes after sacroplasty in a medium-sized uncontrolled cohort of SIF patients.

STUDY DESIGN/SETTING

A prospective observational cohort study of consecutive osteoporotic SIF patients.

PATIENT SAMPLE

Consecutive, osteoporotic patients with symptomatic SIFs electing to enter the study.

OUTCOME MEASURES

Visual Analogue Scale (VAS) score, analgesic utilization, and patient satisfaction.

METHODS

Baseline VAS rating, analgesic usage, and duration of symptoms were recorded. Subsequent VAS ratings were assessed within 30 minutes after the procedure, at 2-, 4-, 12-, 24-, and 52-week postprocedure. Analgesic usage and patient satisfaction were assessed at final follow-up. Each procedure was performed under light intravenous conscious sedation using fluoroscopy. Two bone trochars were inserted between the sacral foramen and sacroiliac joint through which 2 to 3 cc of PMMA were injected.

RESULTS

Fifty-two patients, 40 females, were treated. The mean age was 75.9 years with a mean symptom duration of 34.5 days. All patients were available at each follow-up interval except one patient who died because of unrelated pulmonary disease before the 4-week follow-up. The mean VAS score at baseline was 8.1 and 3.4 within 30 minutes after the procedure, 2.5 at 2, 2.1 at 4, 1.7 at 12, 1.4 at 24, and 0.8 at 52 weeks. Improvement was statistically significant using a repeated measures single-factor analysis of variance. One case of transient S1 radiculitis occurred but resolved completely with one transforaminal epidural steroid injection.

CONCLUSIONS

Sacroplasty for SIF appears to be associated with rapid and sustained pain relief in most patients with few complications. More rigorous trials are warranted to provide definitive evidence of the safety and efficacy of sacroplasty for SIFs.

A comparison of computerized dynamic posturography therapy to standard balance physical therapy in individuals with Parkinson's disease: a pilot study

Postural instability is a common impairment in idiopathic Parkinson's disease (PD). People with PD are prone to balance and walking difficulties. This study analyzed the feasibility of a prospective investigation of Computerized Dynamic Posturography (CDP) and standard Physical Therapy (PT) treatments in individuals with mild-moderate PD. Treatment took place at two sites: 1) CDP therapy at the Southeast Parkinson's Disease Research Education and Clinical Center (PADRECC) within a Veterans Affairs Medical Center and 2) standard physical therapy at a community outpatient rehabilitation center. Final analysis compared 15 patients randomly assigned for therapy to either the CDP or PT treatments. Therapy time was eight weeks (four weeks of CPD or PT followed by home therapy for four weeks). The CDP therapy included gradually intensified closed chain and mobility training. Standard PT consisted of upright, mat, and theraball exercises and gait training. The home exercise phase was identical for both groups. The pilot data demonstrated treatment was tolerated by 68 percent of the sample despite the occurrence of a progressive neurological condition and medical comorbidities. While results failed to reveal any differences between treatment groups, both groups demonstrated improvement on selected outcome measures. An expanded prospective study with methodological improvements appears warranted.

Caregiver distress in parkinsonism

This study examined the frequency and degree of caregiver burden in persons with parkinsonism, a group of disorders with four primary symptoms that include tremor, rigidity, postural instability, and bradykinesia. We assessed associations between perceived caregiver burden and physical, cognitive, and functional impairments using well-established tools for persons with parkinsonism. The 49 individuals with parkinsonism ranged in age from 61 to 87 (mean = 75), while their caregivers (N = 49) ranged in age from 48 to 83 (mean = 70). The caregivers were predominantly either wives (82%) or daughters (6%), with other family members, friends, and/or neighbors (12%) making up the rest. The caregivers reported a relatively high ability for coping (mean scores = 4.6/6). Caregiver burden was significantly negatively associated with activities of daily living and motoric difficulties as measured on the Unified Parkinson's Disease Rating Scale (UPDRS). Likewise, caregiver burden was negatively associated with caregiver self-reported sleep and coping ability. Results did not demonstrate an association on the UPDRS among mentation, behavior, and mood. We found a significant negative correlation for mentation between the Folstein Mini-Mental Status Examination and caregiver burden measures; however, we did not find this association with the Dementia Rating Scale-2. Patient's self-reported pain and caregiver burden were not associated.

Validating the Berg Balance Scale for patients with Parkinson’s disease: A key to rehabilitation evaluation

OBJECTIVE

To assess the criterion-related validity of the Berg Balance Scale (BBS) in subjects with Parkinson's disease (PD).

DESIGN

Prospective, correlational analysis between the BBS and accepted measures of PD motor and functional impairment.

SETTING

The federally funded PD research center, an interdisciplinary center of excellence for people with PD within a Veterans Affairs medical center.

PARTICIPANTS

Thirty-eight men (average +/- standard deviation, 71.1+/-10.5 y) with confirmed PD. Their initial diagnosis had been made on average 5.8+/-3.6 years earlier. All could stand or walk unassisted and had mild to moderate disability. Patients who could not ambulate without assistive devices were excluded.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Correlational analyses between the BBS and the Unified Parkinson's Disease Rating Scale (UPDRS) motor scale, Modified Hoehn and Yahr Staging (Hoehn and Yahr) Scale, and the Modified Schwab and England Capacity for Daily Living Scale (S&E ADL Scale).

RESULTS

BBS score showed significant correlations with indicators of motor functioning, stage of disease, and daily living capacity. BBS score was inversely associated with the UPDRS motor score (-.58, P <.005), Hoehn and Yahr Scale staging (-.45, P <.005), and S&E ADL Scale rating (.55, P <.005). In all 3 correlations, lower scores on the BBS (indicating greater balance deficits) correlated with higher UPDRS scores (indicating greater motoric or functional impairment).

CONCLUSIONS

Results support the criterion-related validity of the BBS. Its utility in other balance conditions of older adults has been established. Rehabilitation interventions have been shown to improve the balance deficits associated with PD. Early referral and periodic reassessment is vital to achieving and maintaining improvements. Our research results agree with other published research in suggesting that the BBS may be used as a screening tool and ongoing assessment tool for patients with PD.

Efficacy of multidisciplinary treatment program on long-term outcomes of individuals with Parkinsons disease

We examined the impact of multidisciplinary clinical management of the Parkinson's Disease Research, Education, and Clinical Center program on Parkinson's disease progression. Initial and follow-up scores on the Part III Motor Examination subscale of the Unified Parkinson's Disease Rating Scale (UPDRS) were examined. Overall, 37 (75.5%) of the 49 patients demonstrated stable or improved UPDRS motor scores at 1- to 3-year follow-up; in the 1-year group (n = 28), 22 patients (78.6%) improved, while 6 (21.4%) worsened. In the 2-year group (n = 15), 10 (66.7%) improved, while 5 (33.3%) worsened. In the 3-year group (n = 6), 5 (83.3%) improved, while 1 (16.7%) worsened. Multidisciplinary interventions included neurology (95.9% of patients), physiatry (93.9%), nursing (87.8%), psychology (42.9%), medication changes (59.2% increases, 18.4% decreases), rehabilitation therapies (physical, occupational, speech-language, 67.3%), functional diagnostic testing (18.4%), support group (16.3%), home exercise instruction (85.7%), and disease and wellness education (81.6%). Improved and worsened patients did not significantly differ on the individual program components. Clinical implications and study limitations are discussed.

Efficacy of a multidisciplinary treatment program on one-year outcomes of individuals with Parkinson's disease

The efficacy of the multidisciplinary treatment approach to the management of Parkinson's disease (PD) was examined at a regional Veteran's Administration Parkinson's Disease Research, Education and Clinical Center (PADRECC). The records of 43 consecutive individuals with PD were examined. The Unified Parkinson's Disease Rating Scale (UPDRS) was employed to assess disease progression. Changes between initial and one-year follow-up UPDRS motor functioning (Part III) scores were compared to expected disease progression from prior research. In this cohort, thirty patients (69.8%) had improved, 2 were unchanged (4.7%) and 11 patients (25.6%) had worsened at the mean 12.2-month follow-up period. The range of multidisciplinary interventions included neurology (100%), physiatrist (93%), and psychology (41.9%) visits, medication changes (60.5%), rehabilitation therapy (62.8%), functional diagnostic testing (16.3%), support group (9.3%), home exercise programs (86%), and disease and wellness education (83.7%). Statistical analyses of the individual components of the program did not demonstrate significant differences between improvers and non-improvers. Clinical implications and study limitations are discussed.