Brain Gains: A Review of Remediation Treatment Strategies Using Exercise following Traumatic Brain Injury

XV. Steroids

Defense and Veterans Brain Injury Center: The First 25 Years

To investigate associations of lifetime history of traumatic brain injury (TBI) with prescription opioid use and misuse among noninstitutionalized adults. Ohio Behavioral Risk Factor Surveillance System (BRFSS) participants in the 2018 cohort who completed the prescription opioid and lifetime history of TBI modules (n = 3448). Secondary analyses of a statewide population-based cross-sectional survey. Self-report of a lifetime history of TBI using an adaptation of the Ohio State University TBI-Identification Method. Self-report of past year: (1) prescription pain medication use (ie, prescription opioid use); and (2) prescription opioid misuse, defined as using opioids more frequently or in higher doses than prescribed and/or using a prescription opioid not prescribed to the respondent. In total, 22.8% of adults in the sample screened positive for a lifetime history of TBI. A quarter (25.5%) reported past year prescription opioid use, and 3.1% met criteria for prescription opioid misuse. A lifetime history of TBI was associated with increased odds of both past year prescription opioid use (adjusted odds ratio [AOR] = 1.52; 95% CI, 1.27-1.83; P < .01) and prescription opioid misuse (AOR = 1.65; 95% CI, 1.08-2.52; P < .05), controlling for sex, age, race/ethnicity, and marital status. Results from this study support the "perfect storm" hypothesis-that persons with a history of TBI are at an increased risk for exposure to prescription opioids and advancing to prescription opioid misuse compared with those without a history of TBI. Routine screening for a lifetime history of TBI may help target efforts to prevent opioid misuse among adults.

Neuropsychiatric Complications of Traumatic Brain Injury: A Critical Review of the Literature (A Report by the ANPA Committee on Research)

The Neuroendocrine Effects of Traumatic Brain Injury

Neuroendocrine dysfunction after traumatic brain injury (TBI) is under-diagnosed, under-treated, and may adversely affect the rate of recovery. Single or multiple pituitary-target hormone disruption occurs in up to two-thirds of persons with TBI, most commonly affecting the gonadal and growth hormone axes. The time course of decline in and recovery of pituitary function in relation to cognitive dysfunction and rehabilitation progress are not well described. This article reviews the clinical spectrum of neuroendocrine deficits after TBI and their underlying mechanisms. Future studies of the effects of hormonal replacement on recovery are recommended.

To investigate the impact of traumatic injury on the developing prefrontal-temporal adolescent cortex, and correlated brain structural measures with neurocognitive functioning. Nineteen adolescents (12 males, 7 females, age range: 11-17y, mean 15y 8mo, standard deviation 1y 7mo, median 15y 11mo) with traumatic brain injury (TBI) were included. Cortical thickness of frontal and temporal lobes was assessed using magnetic resonance imaging. We correlated cortical thickness of prefrontal-temporal regions with age, time since injury, and neurocognitive functioning, and compared these results with a matched control cohort without TBI. We found thinner prefrontal (p=0.039) and temporal cortices (p=0.002) in adolescents with TBI compared to typically developing children. Furthermore, significant age effect was observed on the prefrontal (r=-0.75, p=0.003) and temporal (r=-0.66, p=0.013) cortical thickness in typically developing adolescents, but not in adolescents with TBI. Executive function (measured using the Behaviour Rating Inventory of Executive Function questionnaire, with lower scores meaning higher functioning) was correlated with prefrontal cortical thickness in typically developing adolescents (r=0.72, p=0.009). Opposite trends were found for correlations between cortical thickness and executive function in the TBI and control cohort. Structural maturation in typically developing adolescents correlates with functional development: the older the adolescent, the thinner the prefrontal cortex, the better executive function. In adolescents with TBI we observed an opposite trend, that appeared significantly different from the control group: the thinner the prefrontal and temporal cortex, the worse executive functioning. Cortical thickness is negatively correlated with age in typically developing adolescents. Prefrontal cortex thickness correlates negatively with executive function in typically developing adolescents. Correlations between cortical thickness and executive functioning rise for adolescents without traumatic brain injury (TBI). Correlations between cortical thickness and executive functioning fall for adolescents with TBI. Adolescents with TBI have a long-term impairment of adaptive functioning in daily living.

Personal Bankruptcy After Traumatic Brain or Spinal Cord Injury: The Role of Medical Debt

Does donor cause of death affect the outcome of lung transplantation?

You have accessThe ASHA LeaderFeature1 Jul 2009Improving Inpatient and Follow-Up TBI Services Carlee W. Jones andMS, CCC-SLP Carolyn FoleyRN Carlee W. Jones Google Scholar More articles by this author , MS, CCC-SLP and Carolyn Foley Google Scholar More articles by this author , RN https://doi.org/10.1044/leader.FTR3.14092009.18 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In Even though up to 2 million people sustain traumatic brain injury (TBI) each year, their long-term physical, behavioral and/or cognitive impairments may remain under-diagnosed and untreated (NIH, 1999). The resulting disorders frequently result in functional limitations (Cicerone et al., 2005; Coelho, DeRuyter, & Stein, 1996). As a level-one trauma center, Duke University Hospital routinely admits patients with TBI to the Adult Trauma Service. The Division of Speech Pathology and Audiology provides speech-language, cognitive, and swallowing services to all patients at Duke, including those with TBI. In the past, referral to speech pathology for cognitive-communicative TBI assessment was limited to those patients whose physicians specifically asked for the assessment. However, the attending physician’s focus in treating these multi-injured trauma patients was frequently on resuscitation, stabilization, and treatment to maintain life. Confounding factors—such as baseline substance abuse/withdrawal, psychiatric issues, and hospital sedation—coupled with brief, generic, and informal physician- or nurse-administered cognitive examinations resulted in under-identification of mild and even moderate TBI. As a consequence, referral for speech pathology evaluation and treatment of the resulting cognitive-communicative disorders was inconsistent and underutilized. In an attempt to improve service provision, the speech pathology and trauma service coordinators joined forces to conduct a performance improvement project. Their goal was to identify the scope, need, and utilization of services to determine if the identification of and intervention with patients with TBI could be improved. This project, conducted in five phases, led to an alternative model of service delivery that improved and enhanced services to this population. Phase One: Identification of Need The first step was to identify the use of existing services through a retrospective review of all speech pathology consults for inpatients with TBI admitted to the adult trauma service during a 60-day time period. Results showed that physicians ordered speech pathology consults for cognitive-communicative evaluation for less than 10% of patients that met TBI criteria. These criteria included Glasgow Coma Scale (GCS) < 15; positive brain CT; loss of consciousness; report of amnesia; altered mental status; and/or a traumatic mechanism of injury such as ejection from a motor vehicle (Kay et al., 1993). Based on this retrospective review, the speech pathology and trauma coordinators developed a two-pronged approach to improve service provision to TBI patients that includes: Educating care providers, patients, and patients’ families about TBI. Improving service delivery to patients with TBI. Phase Two: Improved Clinical Education and Service Delivery The clinical education focus for the Division of Speech Pathology and Audiology was to enhance knowledge and skills in TBI management, implement new practice patterns, and improve service delivery. An intensive TBI education program was developed and provided to all clinicians. In addition, a speech-language pathologist was identified to coordinate all services to inpatients in the Adult Trauma Service. This SLP addressed all consults, attended all trauma rounds to advocate for necessary cognitive-communicative services, participated in discharge planning, and served as a consistent physical reminder of the services provided by speech pathology. The multidisciplinary team embraced all of these changes. Another SLP also began to attend the weekly Outpatient Trauma Clinic that provides medical follow-up to all trauma patients after discharge. This SLP re-evaluated the cognitive-communicative status of all patients identified as having TBI during their inpatient stay, determined if recommended services were being received, and provided education to patients and their families. Simultaneously, the Adult Trauma Service spearheaded a similar initiative. The speech pathology and trauma coordinators formed a “TBI Advocacy Team” comprising medical professionals from different disciplines (e.g., physical therapy, occupational therapy, social work, patient resources). Meeting regularly, the team identified enhancements related to TBI services specific to their respective disciplines, identified individual and multidisciplinary goals, developed data collection strategies, and accumulated and analyzed data. The team also focused on increasing TBI awareness and education for staff and patients. Additional TBI education (lectures, in-services, etc.) was provided to nurses, physicians, and medical students. Speech pathology staff—with multidisciplinary input—developed a comprehensive patient and family TBI education book that is provided to all inpatients with TBI and their families. Phase Three: Pilot Project The follow-up data collected by the TBI Advocacy Team during Phase Two revealed that the newly implemented educational and service-delivery measures had increased the provision of cognitive-communicative services to 50% of inpatients who met the TBI criteria. Although this statistic represented an improvement, it also indicated that not all patients were receiving necessary services under the existing physician-requested consultation model. After reviewing the data, the Trauma Service medical director initiated a three-month pilot project that revised the existing physician-ordered consultation model to a “standing order” model of screening and evaluation driven by the Division of Speech Pathology and Audiology. During the pilot study, all TBI patients admitted with blunt force injuries above the neck automatically received a TBI screening (using the criteria previously defined) by Speech Pathology within 24 hours of admission. Both “pass” and “fail” results were documented in the medical record. If any of the TBI criteria was met (“fail”), a cognitive-communicative evaluation was automatically conducted. Pilot-study results showed that 100% of adult trauma service admissions meeting TBI criteria received a TBI screening and, when warranted, subsequent cognitive-communicative evaluation. Our unpublished data reveal that approximately one-third of the patients passed the screening and did not require a full cognitive-communicative evaluation. The remaining two-thirds required a full assessment; of those, approximately half needed immediate cognitive-communicative treatment and half were determined to have signs or symptoms of mild TBI that necessitated follow-up services to reevaluate their cognitive-communicative abilities after discharge. Because of the success of the pilot and demonstration of improved services to patients with TBI, the “standing order” model was permanently implemented. Although data on patient outcomes are not available for this pilot project, care of patients with TBI improved as we shifted from providing few or no services to being actively involved with their evaluation and treatment. Phase Four: Improved Re-evaluation As more individuals with TBI were being identified and more cognitive-communicative deficits were being diagnosed, a coordinated discharge follow-up plan was needed. Before the study, most patients with moderate or severe TBI would receive post-discharge TBI follow-up, including cognitive-communicative treatment, either at inpatient rehabilitation facilities or through outpatient services. However, those with mild TBI often did not receive TBI follow-up services, especially high-functioning patients with mild TBI who may have been assessed as “within normal limits” but still had mild impairments. To address this issue, a follow-up plan has been implemented to ensure that all inpatients identified with mild TBI receive adequate post-discharge treatment. This plan attempted to address functional issues likely to surface when the patient with mild TBI is discharged and attempts to resume daily life at home or work—just as more subtle, but equally serious, signs and symptoms of TBI are likely to emerge. Under the new plan, all inpatients who fail the TBI screening receive a re-evaluation four weeks after discharge—even if they functioned at a high level during their hospital stay. By building on the existing Outpatient Trauma Clinic (described in Phase Two), the speech and trauma coordinators implemented a re-evaluation program for discharged inpatients with TBI. Program patients with TBI who receive a medical follow-up are also re-evaluated for recovery of physical, behavioral, and cognitive aspects of TBI. Based on re-evaluation findings, referrals are then made for more comprehensive TBI services (e.g., speech-language treatment, neurology, neuropsychology). Phase Five: Continual Improvements The desire to improve TBI services grew from a small performance improvement project into a full-scale, multidisciplinary service-delivery model change that continues to evolve almost two years later. The TBI Advocacy Team continues to address process improvements and identify new challenges. These new challenges include creating a Multidisciplinary Outpatient TBI Clinic with the appropriate disciplines in one location to further enhance comprehensive follow-up services for TBI patients. The clinic facilitates patient safety, customer satisfaction, and resource utilization efficacy, and has encouraged the expansion of the inpatient screening process and outpatient follow-up to other hospital services (e.g., neurology, neurosurgery, and orthopedics) and to the pediatric population. Expectations remain high for this evolving project, which may serve as a best practice model for hospitals and medical centers across the nation. References Cicerone K.D., Dahlberg C., Malec J.F., Langenbahn D.M., Felicetti T., Kneipp S., et al. (2005). Evidence-based cognitive rehabilitation: Updated review of the literature from 1998 through 2002.Archives of Physical Medicine and Rehabilitation, 861681–1692. CrossrefGoogle Scholar Coelho C., DeRuyter F., & Stein M. (1996). Treatment efficacy: Cognitive-communicative disorders resulting from traumatic brain injury in adults.Journal of Speech and Hearing Research, 39, S5–S17. AbstractGoogle Scholar Kay T., Adams R., Anderson T., Berrol S., Cicerone K., Dahlberg C., et al. (1993). Definition of mild traumatic brain injury.Journal of Head Trauma Rehabilitation, 8, 86–87. Google Scholar NIH Consensus Development Panel on Rehabilitation of Persons with Traumatic Brain Injury (1999). Rehabilitation of persons with traumatic brain injury.Journal of the American Medical Association, 282, 974–983. Google Scholar Author Notes Carlee W. Jones, MS, CCC-SLP, is a clinical coordinator for the Division of Speech Pathology and Audiology at Duke University Hospital. Her professional interests include the evaluation and treatment of adult neurogenic communication and swallowing disorders, especially with the TBI population, and program development. Contact her at [email protected]. Carolyn Foley, RN, is the trauma nurse coordinator at Duke University Hospital. Her clinical interests include participation in and monitoring of trauma patient care and developing performance improvement initiatives. Advertising Disclaimer | Advertise With Us Advertising Disclaimer | Advertise With Us Additional Resources FiguresSourcesRelatedDetailsCited ByAmerican Journal of Speech-Language Pathology30:3 (1074-1089)18 May 2021The Cognitive-Communication Checklist for Acquired Brain Injury: A Means of Identifying, Recording, and Tracking Communication ImpairmentsSheila MacDonald Volume 14Issue 9July 2009 Get Permissions Add to your Mendeley library History Published in print: Jul 1, 2009 Metrics Downloaded 287 times Topicsasha-topicsleader_do_tagleader-topicsasha-article-typesCopyright & Permissions© 2009 American Speech-Language-Hearing AssociationLoading ...

Posttraumatic brain injury patients with depressive symptoms were compared with nondepressed mild and moderate traumatic brain injury (TBI) patients based on their scores on the Rivermead Post-Concussion Symptoms Questionnaire (RPCSQ). A factor analysis demonstrated that the items of the RPCSQ loaded into three factors: mood and cognition, general somatic, and visual somatic symptom groups. Factor scores based on this model were calculated for each group and it was found that depressed subjects reported a greater severity of all three symptom groups compared to nondepressed patients. These results suggest that depression post-TBI may influence patient perception of postconcussion symptoms.

Inflicted Childhood Neurotrauma: New Insight into The Detection, Pathobiology, Prevention, and Treatment of Our Youngest Patients with Traumatic Brain Injury

Cognitive and structural brain abnormalities are common following traumatic brain injury (TBI). The authors compared cognition and brain structure in 14 TBI survivors and 28 matched healthy comparison subjects. TBI survivors showed reduced cerebral volume, due mainly to white matter changes, and poorer attention, psychomotor speed, and memory. Severity of white matter abnormality correlated with worse performance on several cognitive measures that distinguished between groups. Using voxel-based morphometry, regions of reduced white matter concentration were found throughout the cerebrum along with more localized gray matter reductions. Findings suggest that diffuse rather than focal aspects of TBI contribute most to cognitive outcome.

ObjectiveTo determine whether, in patients undergoing rehabilitation after traumatic or hemorrhagic brain injury, seizures and the use of antiepileptic drugs (AEDs) negatively impact on functional outcome, and, in turn, whether prophylactic AED therapy can prevent the development of seizures.DesignObservational retrospective study.SettingHighly specialized inpatient neurorehabilitation clinic.ParticipantsPatients with traumatic brain injury (TBI), or hemorrhagic stroke (HS) consecutively admitted to our neurorehabilitation unit between January 1, 2009, and December 31, 2018.Main measures and variablesPatients' demographic data, neurological status (Glasgow Coma Scale), and rehabilitation outcome (Functional Independence Measure scale), both assessed on admission and on discharge, associated neurosurgical procedures (craniectomy, or cranioplasty), AED use, early or late seizures occurrence, and death during hospitalization.ResultsOf 740 patients, 162 (21.9%) had seizures, and prophylactic AEDs were started in 192 (25.9%). Multivariate logistic regression identified severity of brain injury as a risk factor for acute symptomatic seizures (ASS) in HS (OR = 1.800, 95%CI = 1.133–1.859, p = 0.013), and for unprovoked seizures (US) in TBI (OR = 1.679, 95%CI = 1.062–2.655, p = 0.027). Prophylaxis with AEDs reduced ASS frequency, but, if protracted for months, was associated with US occurrence (HS, p < 0.0001; TBI, p = 0.0002; vs. untreated patients). Presence of US (β = −0.12; p < 0.0001) and prophylaxis with AEDs (β = −0.09; p = 0.002), were associated with poor functional outcome, regardless of age, severity of brain insult, and HS vs. TBI subtype.ConclusionsSeverity of brain injury and occurrence of seizures during neurorehabilitation are the main driver of poor outcome in both HS and TBI. The possible detrimental role on the epileptogenic and functional outcome played by seizures prophylaxis with AEDs, nonetheless useful to prevent ASS if administered over the first week after the brain injury, warrants further investigation.

Psychiatric Sequelae of Traumatic Brain Injury: A Case Report