Placebo-Controlled Trial of Familiar Auditory Sensory Training for Acute Severe Traumatic Brain Injury: A Preliminary Report.

BACKGROUND: Sensory stimulation is often provided to persons incurring severe traumatic brain injury (TBI), but therapeutic effects are unclear. OBJECTIVE: This preliminary study investigated neurobehavioral and neurophysiological effects related to sensory stimulation on global neurobehavioral functioning, arousal, and awareness. METHODS: A double-blind randomized placebo-controlled trial where 15 participants in states of disordered consciousness (DOC), an average of 70 days after TBI, were provided either the Familiar Auditory Sensory Training (FAST) or Placebo of silence. Global neurobehavioral functioning was measured with the Disorders of Consciousness Scale (DOCS). Arousal and awareness were measured with the Coma-Near-Coma (CNC) scale. Neurophysiological effect was measured using functional magnetic resonance imaging (fMRI). RESULTS: FAST (n = 8) and Placebo (n = 7) groups each showed neurobehavioral improvement. Mean DOCS change (FAST = 13.5, SD = 8.2; Placebo = 18.9, SD = 15.6) was not different, but FAST patients had significantly (P = .049; 95% confidence interval [CI] = -1.51, -.005) more CNC gains (FAST = 1.01, SD = 0.60; Placebo = 0.25, SD = 0.70). Mixed-effects models confirm CNC findings (P = .002). Treatment effect, based on CNC, is large (d = 1.88, 95% CI = 0.77, 3.00). Number needed to treat is 2. FAST patients had more fMRI activation in language regions and whole brain (P values <.05) resembling healthy controls' activation. CONCLUSIONS: For persons with DOC 29 to 170 days after TBI, FAST resulted in CNC gains and increased neural responsivity to vocal stimuli in language regions. Clinicians should consider providing the FAST to support patient engagement in neurorehabilitation.

The prevalence of epilepsy and association with traumatic brain injury in veterans of the Afghanistan and Iraq wars.

OBJECTIVE: To examine the association of epilepsy with traumatic brain injury (TBI) in Afghanistan and Iraq (Operation Enduring Freedom [OEF]/Operation Iraqi Freedom [OIF]) Veterans. DESIGN: Cross-sectional observational study. PARTICIPANTS: A total 256 284 OEF/OIF Veterans who received inpatient and outpatient care in the Veterans Health Administration in fiscal years 2009-2010. MAIN OUTCOME MEASURES: We used algorithms developed for use with International Classification of Diseases, Ninth Revision, Clinical Modification, codes to identify epilepsy, TBI (penetrating TBI [pTBI]/other TBI), and other risk factors for epilepsy (eg, stroke). TBI and other risk factors were identified prior to the index date (first date of seizure or October 1, 2009) for primary analyses. RESULTS: Epilepsy prevalence was 10.6 per 1000 (N = 2719) in fiscal year 2010; age-adjusted prevalence was 6.1. Of 37 718 individuals with a diagnosis of TBI, 29 297 Veterans had a diagnosis of TBI prior to the index date. Statistically significant associations were found between epilepsy and prior TBI diagnosis (pTBI: adjusted odds ratio = 18.77 [95% confidence interval, 9.21-38.23]; other TBI: adjusted odds ratio = 1.64 [1.43-1.89]). CONCLUSIONS: Among OEF/OIF Veterans, epilepsy was associated with previous TBI diagnosis, with pTBI having the strongest association. Because war-related epilepsy in Vietnam War Veterans with TBI continued 35 years postwar, a detailed, prospective study is needed to understand the relationship between epilepsy and TBI severity in OEF/OIF Veterans.

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.

Subjective sleep disturbance in veterans receiving care in the Veterans Affairs Polytrauma System following blast-related mild traumatic brain injury.

OBJECTIVES: This investigation sought to characterize prevalence and factors associated with subjective sleep disturbance (SSD) in a clinical sample of veterans with blast-related mild traumatic brain injury (mTBI). METHODS: Adult veterans with history of blast-related mTBI were enrolled in a cross-sectional study. Data on demographics, injury, and current symptoms, including SSD, were obtained. Descriptive and univariate analyses investigated prevalence of SSD and associated factors. RESULTS: Participants were 114 veterans with blast-related mTBI (96% male; mean age = 31 years, SD = 8; mean number of days since injury =1,044, SD = 538). 78% screened positive for post-traumatic stress disorder and 77% reported SSD. Loss of consciousness at time of injury, current nightmares, depression, headache, fatigue, and positive screen for post-traumatic stress disorder were significantly associated with SSD (p < 0.05). CONCLUSIONS: SSD was pervasive in this clinical sample and was significantly associated with multiple modifiable emotional symptoms as well as headache and fatigue; this is consistent with previous literature including samples with history of nonblast-related mTBI. Future research incorporating objective measurement of SSD and associated symptoms is needed to inform evidence-based screening, assessment, and treatment efforts for veterans with history of mTBI.

Descriptive characteristics and rehabilitation outcomes in active duty military personnel and veterans with disorders of consciousness with combat- and noncombat-related brain injury.

OBJECTIVE: To report the injury and demographic characteristics, medical course, and rehabilitation outcome for a consecutive series of veterans and active duty military personnel with combat- and noncombat-related brain injury and disorder of consciousness (DOC) at the time of rehabilitation admission. DESIGN: Retrospective study. SETTING: Rehabilitation center. PARTICIPANTS: From January 2004 to October 2009, persons (N=1654) were admitted to the Polytrauma Rehabilitation System of Care. This study focused on the N=122 persons admitted with a DOC. Participants with a DOC were primarily men (96%), on active duty (82%), ≥12 years of education, and a median age of 25. Brain injury etiologies included mixed blast trauma (24%), penetrating (8%), other trauma (56%), and nontrauma (13%). Median initial Glasgow Coma Scale score was 3, and rehabilitation admission Glasgow Coma Scale score was 8. Individuals were admitted for acute neurorehabilitation approximately 51 days postinjury with a median rehabilitation length of stay of 132 days. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Recovery of consciousness and the FIM instrument. RESULTS: Most participants emerged to regain consciousness during neurorehabilitation (64%). Average gains ± SD on the FIM cognitive and motor subscales were 19 ± 25 and 7 ± 8, respectively. Common medical complications included spasticity (70%), dysautonomia (34%), seizure occurrence (30%), and intracranial infection (22%). Differential outcomes were observed across etiologies, particularly for those with blast-related brain injury etiology. CONCLUSIONS: Despite complex comorbidities, optimistic outcomes were observed. Individuals with severe head injury because of blast-related etiologies have different outcomes and comorbidities observed. Health-services research with a focus on prevention of comorbidities is needed to inform optimal models of care, particularly for combat injured soldiers with blast-related injuries.

Functional outcomes in traumatic disorders of consciousness: 5-year outcomes from the National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems.

OBJECTIVE: To characterize the 5-year outcomes of patients with traumatic brain injury (TBI) not following commands when admitted to acute inpatient rehabilitation. DESIGN: Secondary analysis of prospectively collected data from the National Institute on Disability and Rehabilitation Research-funded Traumatic Brain Injury Model Systems (TBIMS). SETTING: Inpatient rehabilitation hospitals participating in the TBIMS program. PARTICIPANTS: Patients (N=108) with TBI not following commands at admission to acute inpatient rehabilitation were divided into 2 groups (early recovery: followed commands before discharge [n=72]; late recovery: did not follow commands before discharge [n=36]). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: FIM items. RESULTS: For the early recovery group, depending on the FIM item, 8% to 21% of patients were functioning independently at discharge, increasing to 56% to 85% by 5 years postinjury. The proportion functioning independently increased from discharge to 1 year, 1 to 2 years, and 2 to 5 years. In the late recovery group, depending on the FIM item, 19% to 36% of patients were functioning independently by 5 years postinjury. The proportion of independent patients increased significantly from discharge to 1 year and from 1 to 2 years, but not from 2 to 5 years. CONCLUSIONS: Substantial proportions of patients admitted to acute inpatient rehabilitation before following commands recover independent functioning over as long as 5 years, particularly if they begin to follow commands before hospital discharge.

Treatment of disorders of consciousness in the Veterans Health Administration polytrauma centers.

This article describes the evolution of the emerging consciousness programs and the approach to care for veterans and active duty service members with disorders of consciousness (DOC) at the 4 polytrauma rehabilitation centers of the Veterans Health Administration. Compared to traditional rehabilitation patients, DOC patients have unique recovery patterns and rehabilitative needs, and they require an intensive medical and nursing support structure. This requires closely integrated rehabilitation and acute medical care to ensure the highest level of outcomes. Unfortunately, little information exists in the literature to establish best practices for the rehabilitation of this population. It is the authors' intentions to bridge the literature gap in regard to programmatic structure, treatment approaches for those with DOC, and support of their caregivers. This article includes descriptions of medical care protocols, review of stimulation approaches (environmental and pharmacologic) caregiver support, and monitoring of recovery patterns.

Preliminary framework for Familiar Auditory Sensory Training (FAST) provided during coma recovery.

Since there remains a need to examine the nature of the neural effect and therapeutic efficacy/effectiveness of sensory stimulation provided to persons in states of seriously impaired consciousness, a passive sensory stimulation intervention, referred to as the Familiar Auditory Sensory Training (FAST) protocol, was developed for examination in an ongoing, double-blind, randomized clinical trial (RCT). The FAST protocol is described in this article according to the preliminary framework, which is a synthesis of knowledge regarding principles of plasticity and capabilities of the human brain to automatically and covertly process sensory input. Feasibility issues considered during the development of the intervention are also described. To enable replication of this intervention, we describe procedures to create the intervention and lessons learned regarding the creation process. The potential effect of the intervention is illustrated using functional brain imaging of nondisabled subjects. This illustration also demonstrates the relevance of the rationale for designing the FAST protocol. To put the intervention within the context of the scientific development process, the article culminates with a description of the study design for the ongoing RCT examining the efficacy of the FAST protocol.

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.

Rehabilitation needs of combat-injured service members admitted to the VA Polytrauma Rehabilitation Centers: the role of PM&R in the care of wounded warriors.

OBJECTIVE: To describe the rehabilitation course of combat-injured service members who sustained polytraumatic injuries during the current wars in and around Iraq and Afghanistan. DESIGN: Retrospective descriptive analysis. SETTING: Department of Veterans Administration Polytrauma Rehabilitation Centers (PRCs). PARTICIPANTS: One hundred eighty-eight consecutive, acutely combat-injured service members suffering polytraumatic injuries requiring inpatient rehabilitation and being treated at PRCs between October 2001 and January 2006. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Medications prescribed, devices used, injuries and impairment information, and consultative services. RESULTS: Ninety-three percent of the patients had sustained a traumatic brain injury (TBI) and more than half of these were incurred secondary to blast explosions. Over half of the patients had infections or surgeries prior to PRC admission that required continued medical attention during their stay. Pain and mental health issues were present in 100% and 39%, respectively, of all patients admitted and added complexity to the brain injury rehabilitation process. Common treatment needs included cognitive-behavioral interventions, pain care, assistive devices, mental health interventions for both patients and their families, and specialty consultations, in particular to ophthalmology, otolaryngology, and neurology. CONCLUSIONS: Combat-injured polytrauma patients have complex rehabilitation needs that require a high level of specialized training and skill. Physical medicine and rehabilitation specialists treating war injured service members need a high level of expertise in assessment and treatment of co-occurring pain, TBI, and stress disorders. Physiatrists are playing an important role in providing and coordinating the rehabilitation care for individuals with significant polytraumatic war injuries from the Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) conflicts.

Minimizing the effect of TBI-related physical sequelae on vocational return.

This article evaluated the common physical sequelae that affect return to work (RTW) after traumatic brain injury (TBI). We performed a Medline search and evaluation of current TBI rehabilitation texts. The information presented is a combination of published literature and clinical guidelines. The limitations faced by many patients with TBI can best be overcome through clever job search, job redesign, and community linkages with business and industry that are willing to partner in helping the patient with TBI regain employment. The physician plays a key role in communicating suggestions to the vocational specialist. The comorbidities described represent challenges to successful RTW. These problems are recurrent, long-term, and clearly affect job procurement, nature of job, level of required support, and likelihood of job retention. Conversely, these challenges should not be viewed as impenetrable obstacles. With appropriate supports such as compensatory strategies, job coaching, assistive technology, medical management, and job restructuring, successful RTW is viable option. Physicians must focus on employment outcomes in real jobs and not settle for volunteer work, sheltered work, or assessment and planning. Individuals should be placed in real work for real pay. Through close collaboration between the survivor of TBI, the physician, the vocational specialist, and community resources, successful employment for survivors of TBI is possible and must be prescribed a high value.

Incidence, etiology, and risk factors for fever following acute spinal cord injury.

OBJECTIVE: To identify the incidence, etiology, and risk factors for fevers in individuals with traumatic spinal cord injury (SCI). DESIGN: A retrospective review of the medical records of consecutive adult traumatic SCI patients over a 2-year period was performed. SETTING: The study was performed at a tertiary care, Level I trauma center. PARTICIPANTS: Consecutive adult traumatic SCI admissions to acute care (n = 48) and rehabilitation (n = 40) were included in the study. MAIN OUTCOME MEASURES: Incidence, etiology, mean maximum temperature elevation, and duration of fevers (temperature >99.9 F) were measured. RESULTS: The incidence of fever was 60.4% and 50% (acute care and rehabilitation, respectively). Total number of fevers was 58 and 66, acute and rehabilitation, respectively. Respiratory and urinary tract were the most common identifiable fever etiologies. Unidentified fever etiologies were numerous in both the acute and rehabilitation groups, representing 66% and 56% of cases, respectively. Significant differences (P < 0.05) were found between identified vs unidentified fever etiology groups for mean maximal temperature (102.5 degrees F vs 101.1 degrees F on acute and 101.5 degrees F vs 100.7 degrees F on rehabilitation), duration of fever (10.3 days vs 2.2 on acute and 2.8 days vs 1.3 on rehabilitation), fevers above 101.4 degrees F (75% vs 29% on acute and 40% vs 8% on rehabilitation), cause of injury (gunshot wound on acute care) and completeness of injury (American Spinal Injury Association classification A on rehabilitation). CONCLUSIONS: This study suggests that fevers occur commonly in patients with SCI, with respiratory and genitourinary system etiologies most commonly identified. Unidentified etiologies were common and were associated with lower temperature elevation and shorter fever duration. Injury etiology and completeness of injury may comprise additional risk factors. These factors should be taken into account when initiating cost-efficient fever workup in individuals with SCI.

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.