American Congress Of Rehabilitation Medicine Research Articles

International survey on the implementation of the European and American guidelines on disorders of consciousness

Diagnostic, prognostic, and therapeutic procedures for patients with prolonged disorders of consciousness (pDoCs) vary significantly across countries and clinical settings, likely due to organizational factors (e.g., research vs. non-academic hospitals), expertise and availability of resources (e.g., financial and human). Two international guidelines, one from the European Academy of Neurology (EAN) and one from the American Academy of Neurology (AAN) in collaboration with the American Congress of Rehabilitation Medicine (ACRM) and the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR), were developed to facilitate consistent practice among professionals working with this challenging patient population. While the recommendations of both guidelines agree in principle, it remains an open issue how to implement them into clinical practice in the care pathway for patients with pDoCs. We conducted an online survey to explore health professional clinical practices related to the management of patients with pDoCs, and compare said practices with selected recommendations from both the guidelines. The survey revealed that while some recommendations are being followed, others are not and/or may require more honing/specificity to enhance their clinical utility. Particular attention should be given to the implementation of a multimodal assessment of residual consciousness, to the detection and treatment of pain, and to the impact of restrictions imposed by COVID-19 pandemics on the involvement of patients’ families/representatives.

Association of Traumatic Brain Injury, Mild Cognitive Impairment and Dementia in the Framingham Heart Study’s Original Cohort (S39.009)

<h3>Objective:</h3> To estimate the associations between traumatic brain injury (TBI), mild cognitive impairment (MCI), all-cause dementia, and Alzheimer’s disease (AD) dementia. <h3>Background:</h3> Research on the relationship between TBI, AD and AD related dementias is inconsistent. <h3>Design/Methods:</h3> The Framingham Heart Study (FHS) is a population-based cohort study which recruited its original cohort, ages 30–62, between 1948–1950. Information on TBIs was collected by self-report and comprehensive review of medical records obtained through FHS health history updates until death. TBI occurrence and severity were operationalized using modified American Congress of Rehabilitation Medicine and Veterans Affairs/Department of Defense criteria respectively. MCI, dementia, and AD dementia consensus diagnoses were operationalized using modified Peterson criteria, Diagnostic and Statistical Manual of Mental Disorders, 4^th edition, and National Institute of Neurological and Communicative Diseases and Stroke/AD and Related Disorders Association criteria respectively. <h3>Results:</h3> The study included 715 participants with TBI and 2145 age- and sex-matched participants without TBI who were cognitively normal at time of TBI and followed for an average of 16±17 years. 567 (26.43%), 461 (21.49%) and 373 (17.39%) participants without TBI developed MCI, all cause dementia and AD dementia respectively compared with 271 (37.9%), 218 (30.49%) and 131 (21.12%) of those with TBI. For mild TBI, hazard ratios (HRs) for MCI, all-cause dementia and AD dementia were 1.55 (95%CI 1.14–2.12), 1.47 (95%CI 1.02–2.14), and 1.06 (95%CI 0.68–1.66) respectively. For moderate-to-severe TBI, HRs for MCI, all cause dementia and AD dementia were 3.50 (95%CI 1.10–11.17), 4.61 (95%CI 0.96–22.14), and 6.36 (95%CI 0.72–56.50) respectively. <h3>Conclusions:</h3> In this cohort followed for more than a decade and comprehensively assessed for TBI and dementia-related outcomes, there were small to moderate sized associations of mild TBI and large associations of moderate-severe TBI with MCI and all-cause dementia. Association between mild TBI and dementia may be driven by non-AD etiologies. <b>Disclosure:</b> Dr. Durape has nothing to disclose. Dr. Joshi has nothing to disclose. Ms. Burton has nothing to disclose. Mr. Chien-Young has received research support from the National Heart, Lung, And Blood Institute of the National Institutes of Health under Award Number T35HL139444. Miss Price has nothing to disclose. Miss Shanabrook has nothing to disclose. Miss Yhang has nothing to disclose. Mrs. Liu has nothing to disclose. The institution of Dr. Ang has received research support from NIH. Dr. Devine has nothing to disclose. Dr. Gurnani has nothing to disclose. Dr. Katz has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for Law firms. The institution of Dr. Katz has received research support from NINDS/NIH. Dr. Katz has received publishing royalties from a publication relating to health care. Yorghos Tripodis, 5406 has nothing to disclose. The institution of Michael Alosco, PHD has received research support from NIH. Dr. Dams-O’Connor has received personal compensation in the range of $500-$4,999 for serving as an Expert Witness for Various law firms. The institution of Dr. Dams-O’Connor has received research support from NIH. The institution of Dr. Dams-O’Connor has received research support from Department of Defense. The institution of Dr. Dams-O’Connor has received research support from National Institute on Disability Independent Living and Rehabilitation Research. The institution of Dr. Dams-O’Connor has received research support from Patient Reported Outcomes Research Institute. Dr. Au has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Biogen. Dr. Au has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Merck. Dr. Au has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Novartis. Dr. Au has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for NovoNordisk. Dr. Au has received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for GSK. Dr. Au has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Eisai. Dr. Au has received publishing royalties from a publication relating to health care. Dr. Au has received personal compensation in the range of $50,000-$99,999 for serving as a Consultant with Davos Alzheimer’s Collaborative. Dr. Au has received personal compensation in the range of $50,000-$99,999 for serving as a Consultant with High Lantern. The institution of Dr. Mez has received research support from NIH, DOD.

Do concussed and non-concussed head trauma individuals have similar symptoms? A retrospective chart review of chronic post-concussive symptomatology

Many head trauma patients who present with prolonged post-concussion symptoms do not meet the American Congress of Rehabilitation Medicine (ACRM) diagnostic criteria for mild traumatic brain injuries (mTBI). This population has not been extensively studied and its clinical characteristics are currently uncertain. A retrospective chart review was conducted to explore the symptomatic differences between mTBI and non-mTBI head trauma patients presenting at a concussion clinic with chronic post-concussion symptoms (PCSx). Patient information was extracted from 161 charts, of which 128 subjects met the ACRM criteria for mTBI (ACRM + PCSx), while 33 did not (non-ACRM + PCSx). These two groups were compared for demographic variables and symptomology. This study found that 20.5% of subjects presenting with chronic post-concussion symptoms do not meet ACRM criteria. No symptom-specific differences were found between the two populations in any of the categories tested. These results show that chronic post-concussion symptoms are similar in both mTBI and non-mTBI head trauma patients in the general population, suggesting a need for further research focusing on this group.

Prospective Study of Gray Matter Atrophy Following Pediatric Mild Traumatic Brain Injury.

The clinical and physiologic time course for recovery following pediatric mild traumatic brain injury (pmTBI) remains actively debated. The primary objective of the current study was to prospectively examine structural brain changes (cortical thickness and subcortical volumes) and age-at-injury effects. A priori study hypotheses predicted reduced cortical thickness and hippocampal volumes up to 4 months postinjury, which would be inversely associated with age at injury. Prospective cohort study design with consecutive recruitment. Study inclusion adapted from American Congress of Rehabilitation Medicine (upper threshold) and Zurich Concussion in Sport Group (minimal threshold) and diagnosed by Emergency Department and Urgent Care clinicians. Major neurologic, psychiatric, or developmental disorders were exclusionary. Clinical (Common Data Element) and structural (3 T MRI) evaluations within 11 days (subacute visit [SA]) and at 4 months (early chronic visit [EC]) postinjury. Age- and sex-matched healthy controls (HC) to control for repeat testing/neurodevelopment. Clinical outcomes based on self-report and cognitive testing. Structural images quantified with FreeSurfer (version 7.1.1). A total of 208 patients with pmTBI (age = 14.4 ± 2.9; 40.4% female) and 176 HC (age = 14.2 ± 2.9; 42.0% female) were included in the final analyses (>80% retention). Reduced cortical thickness (right rostral middle frontal gyrus; d = -0.49) and hippocampal volumes (d = -0.24) observed for pmTBI, but not associated with age at injury. Hippocampal volume recovery was mediated by loss of consciousness/posttraumatic amnesia. Significantly greater postconcussive symptoms and cognitive deficits were observed at SA and EC visits, but were not associated with the structural abnormalities. Structural abnormalities slightly improved balanced classification accuracy above and beyond clinical gold standards (∆+3.9%), with a greater increase in specificity (∆+7.5%) relative to sensitivity (∆+0.3%). Current findings indicate that structural brain abnormalities may persist up to 4 months post-pmTBI and are partially mediated by initial markers of injury severity. These results contribute to a growing body of evidence suggesting prolonged physiologic recovery post-pmTBI. In contrast, there was no evidence for age-at-injury effects or physiologic correlates of persistent symptoms in our sample.

A Delphi technique toward the development of a cognitive intervention framework module for breast cancer survivors with cognitive impairment following chemotherapy.

Chemotherapy-related cognitive impairment (CRCI) is a well-known phenomenon among breast cancer survivors. Cognitive impairment among breast cancer survivors can significantly affect their quality of life and ability to function independently. However, there is a lack of specific and focused cognitive intervention to improve their cognitive performances. This study aimed to develop a tailored cognitive intervention framework module by adapting the attention and memory interventions from the Cognitive Rehabilitation Manual of the Brain Injury Interdisciplinary Special Interest Group (BI-SIG) of the American Congress of Rehabilitation Medicine (ACRM) and incorporating them with the relevant exercises for cognitive rehabilitation for Malaysian breast cancer survivors with CRCI based on the consensus agreement of the expert panel. The Delphi consensus technique was conducted online to review and evaluate the framework module. A panel of experts, including rehabilitation medicine physicians, occupational therapists, and clinical psychologists in Malaysia, was invited to participate in this study. For each round, the expert consensus was defined as more than 90% of the expert panel agreeing or strongly agreeing with the proposed items. A total of 33 practitioners completed the three Delphi rounds. 72.7% of the expert panel have been practising in their relevant clinical fields for more than six years (M = 10.67, SD = 5.68). In Round 1, 23% of the experts suggested that the framework module for attention training required further improvements, specifically in the language (M = 1.97, SD = 0.75) and instructions (M = 2.03, SD = 0.71) provided. In Round 2, 15% of the experts recommended additional changes in the instruction (M = 2.15, SD = 0.67) for attention training. Amendments made to the framework module in line with the recommendations provided by the experts resulted in a higher level of consensus, as 94% to 100% of the experts in Round 3 concluded the framework module was suitable and comprehensive for our breast cancer survivors. Following the key results, the objectives were practical, and the proposed approaches, strategies, and techniques for attention and memory training were feasible. The clarity of the instructions, procedures, verbatim transcripts, and timeframe further enhanced the efficacy and utility of the framework module. This study found out that the cognitive intervention framework module for breast cancer survivors with cognitive impairment following chemotherapy can be successfully developed and feasible to be implemented using Delphi technique.

American and European Guidelines on Disorders of Consciousness: Ethical Challenges of Implementation.

American and European Guidelines on Disorders of Consciousness: Ethical Challenges of Implementation.

The neuroethics of disorders of consciousness: a brief history of evolving ideas.

Neuroethical questions raised by recent advances in the diagnosis and treatment of disorders of consciousness are rapidly expanding, increasingly relevant and yet underexplored. The aim of this thematic review is to provide a clinically applicable framework for understanding the current taxonomy of disorders of consciousness and to propose an approach to identifying and critically evaluating actionable neuroethical issues that are frequently encountered in research and clinical care for this vulnerable population. Increased awareness of these issues and clarity about opportunities for optimizing ethically responsible care in this domain are especially timely given recent surges in critically ill patients with prolonged disorders of consciousness associated with coronavirus disease 2019 around the world. We begin with an overview of the field of neuroethics: what it is, its history and evolution in the context of biomedical ethics at large. We then explore nomenclature used in disorders of consciousness, covering categories proposed by the American Academy of Neurology, the American Congress of Rehabilitation Medicine and the National Institute on Disability, Independent Living and Rehabilitation Research, including definitions of terms such as coma, the vegetative state, unresponsive wakefulness syndrome, minimally conscious state, covert consciousness and the confusional state. We discuss why these definitions matter, and why there has been such evolution in this nosology over the years, from Jennett and Plum in 1972 to the Multi-Society Task Force in 1994, the Aspen Working Group in 2002 and the 2018 American and 2020 European Disorders of Consciousness guidelines. We then move to a discussion of clinical aspects of disorders of consciousness, the natural history of recovery and ethical issues that arise within the context of caring for people with disorders of consciousness. We conclude with a discussion of key challenges associated with assessing residual consciousness in disorders of consciousness, potential solutions and future directions, including integration of crucial disability rights perspectives.

Contribution of Peripheral Injuries to the Symptom Experience of Patients with Mild Traumatic Brain Injury.

Peripheral injuries are common in patients who experience mild traumatic brain injury (mTBI). However, the additive or interactive effects of polytrauma on psychosocial adjustment, functional limitations, and clinical outcomes after head injury remain relatively unexamined. Using a recently developed structured injury symptom interview, we assessed the perception and relative importance of peripheral injuries at 3 months post-injury in patients with mTBI as defined by the American Congress of Rehabilitation Medicine. Our sample of Level 1 trauma patients (n = 74) included individuals who were treated and released from the emergency department (n = 43) and those admitted to an inpatient unit (n = 31). Across the sample, 91% of patients with mTBI experienced additional non-head injuries known to commonly impact recovery following mTBI, a majority of whom ranked pain as their worst peripheral injury symptom. Forty-nine percent of the mTBI sample (54% of the subsample with concurrent mTBI and peripheral injuries) reported being more bothered by peripheral injury symptoms than mTBI. Differences between patients with mTBI with worse mTBI symptoms versus those with worse peripheral injury symptoms are described. Conventional measures of injury severity do not capture patients' perceptions of the totality of their injuries, which limits the development of patient-centered treatments. Future research should enroll patients with mTBI diverse in peripheral injury severity and develop standardized assessments to characterize peripheral symptoms, enabling better characterization of the relevance of concurrent injuries in recovery and outcomes of patients with mTBI.

From the Editors-A Welcome and a THANK YOU!

ON BEHALF OF THE EDITORS and Publisher of the Journal of Head Trauma Rehabilitation (JHTR), I would like to welcome Brad G. Kurowski, MD, MS, as a new Associate Editor. Dr Kurowski brings multiple domains of expertise to the Editorial staff and has an active research portfolio in pediatric traumatic brain injury. He is an Associate Professor at the University of Cincinnati in the Departments of Pediatrics and Neurology & Rehabilitation Medicine. At Cincinnati Children's Medical Center, Dr Kurowski is Co-Director of the Brain Recovery After Injury (BRAIN) Health and Wellness Center and Director of the Brain Injury Rehabilitation Program in the Division of Physical Medicine and Rehabilitation. We are very pleased to have such an accomplished researcher joining the Editorial staff of JHTR. We welcome Dr Kurowski because Dr Bruce Caplan has decided to retire from his role as the Senior Editor of JHTR. I know the other Editors and our Publisher join me in extending a heartfelt “THANK YOU” to Dr Caplan for his decades of service to JHTR. On a recent Editorial Board call, Dr Nat Mayer, former Senior Editor, detailed the substantial history of Dr Caplan's involvement with the journal: In March 1986, Shelly Berrol and Mitch Rosenthal inaugurated JHTR with Dr Caplan as a member of the Editorial Board. Volume 1, Number 1 of JHTR included a book review by Dr Caplan of Barbara Wilson's Clinical Management of Memory Problems. In September 1992, Bruce was formally named as Special Features Editor for Book Reviews. In December 1994, JHTR announced a bimonthly expansion from 4 to 6 issues to include 2 nonthematic issues focusing on clinical research and practice. Dr Caplan was appointed as an Associate Editor managing unsolicited submissions for these two issues. With the untimely passing of Mitch Rosenthal in 2007, Dr Caplan was named a Senior Editor and with Dr Mayer guided JHTR through its transition to a new Editor-in-Chief. To this day, Dr Caplan has continued to serve as a Senior Editor and valued consultant. JHTR is not the only professional journal to have benefited from Dr Caplan's editorial acumen—he was a significant contributor to the Archives of Physical Medicine and Rehabilitation, and served as Editor-in-Chief of Rehabilitation Psychology. He has also served as Editor of a number of preeminent reference texts in rehabilitation and neuropsychology. Dr Caplan's many-faceted expertise is reflected in his Board certification in both Rehabilitation Psychology and Clinical Neuropsychology. It's no wonder he holds Fellow status in the American Psychological Association, the National Academy of Neuropsychology, and the American Congress of Rehabilitation Medicine. Thank you, Dr Caplan for your contribution to JHTR and the entire field of rehabilitation. On a personal note, I cannot thank Bruce enough for the guidance he has provided me in my role as Editor-in-Chief. Whether determining how to handle a specific paper or conceptualizing a policy implied by the decision, Bruce has always been able to balance the scientific needs of the journal with the pragmatic experience of an author or reviewer. Your impact on this journal and our field is immeasurable. John D. Corrigan, PhD Editor-in-Chief

Brigid Dwyer, MD, and Douglas I. Katz, MD.

Dr. Dwyer is Assistant Professor of Neurology at Boston University (BU) School of Medicine. She received her BS from Massachusetts Institute of Technology in Brain and Cognitive Sciences, and her MD from the Warren Alpert School of Medicine at Brown University. She did her internship in Internal Medicine, as well as her residency in Neurology, at BU. This was followed by a clinical and research fellowship in Brain Injury Medicine and Neurorehabilitation sponsored by the BU School of Medicine and the Boston Veterans Affairs Healthcare System. She joined BU's faculty in 2017, where she has served admirably. She is currently Director of the Vascular Injury/Stroke Program at Encompass Health Braintree Rehabilitation Hospital, where she also serves on the Medical Executive Committee. She serves on numerous American Congress of Rehabilitation Medicine (ACRM) committees, including the Disorders of Consciousness Working Group, the Physicians and Clinicians Working Group, and the Brain Injury Interdisciplinary Special Interest Group. She is a revered clinician and teacher, and a rising star in the field of Brain Injury Medicine.

Expert Panel Survey to Update the American Congress of Rehabilitation Medicine Definition of Mild Traumatic Brain Injury

ObjectiveAs part of an initiative led by the Brain Injury Special Interest Group Mild Traumatic Brain Injury (TBI) Task Force of the American Congress of Rehabilitation Medicine (ACRM) to update the 1993 ACRM definition of mild TBI, the present study aimed to characterize current expert opinion on diagnostic considerations. DesignCross-sectional web-based survey. SettingNot applicable. ParticipantsAn international, interdisciplinary group of clinician-scientists (N=31) with expertise in mild TBI completed the survey by invitation between May and July 2019 (100% completion rate). InterventionsNot applicable. Main Outcome MeasuresRatings of agreement with statements related to the diagnosis of mild TBI and ratings of the importance of various clinical signs, symptoms, test findings, and contextual factors for increasing the likelihood that the individual sustained a mild TBI, on a scale ranging from 1 (“not at all important”) to 10 (“extremely important”). ResultsMen (n=25; 81%) and Americans (n=21; 68%) were over-represented in the sample. The survey revealed areas of expert agreement (eg, acute symptoms are diagnostically useful) and disagreement (eg, whether mild TBI with abnormal structural neuroimaging should be considered the same diagnostic entity as “concussion”). Observable signs were generally rated as more diagnostically important than subjective symptoms (Wilcoxon signed ranks test, Z=3.77; P<.001; r=0.68). Diagnostic importance ratings for individual symptoms varied widely, with some common postconcussion symptoms (eg, fatigue) rated as unhelpful (<75% of respondents indicated at least 5 out of 10 importance). Certain acute test findings (eg, cognitive and balance impairments) and contextual factors (eg, absence of confounds) were consistently rated as highly important for increasing the likelihood of a mild TBI diagnosis (≥75% of respondents indicated at least 7 out of 10). ConclusionsThe expert survey findings identified several potential revisions to consider when updating the ACRM mild TBI definition, including preferentially weighing observable signs in a probabilistic framework, incorporating symptoms and test findings, and adding differential diagnosis considerations.

Definition and epidemiology of mild traumatic brain injury

Background/objectivesThe definition of mild traumatic brain injury (mTBI), also known as concussion, has been a matter of controversy, which makes comparison between studies difficult. Incidence varies greatly from one country to another. The present article reviews definitions and epidemiology. MethodsLiterature review. ResultsAccording to the Mild TBI Committee of the American Congress of Rehabilitation Medicine, revised by the World Health Organization (WHO), mTBI is defined by a Glasgow Coma Scale score between 13 and 15 at 30minutes post-injury, and one or more of the following symptoms: <30min loss of consciousness; <24hours post-traumatic amnesia (PTA); impaired mental state at time of accident (confusion, disorientation, etc.); and/or transient neurological deficit. If a focal lesion is found on computed tomography (CT) or magnetic resonance imaging (MRI), the term “complicated mild TBI” has been proposed. Incidence of mTBI is 200–300/100,000 persons per year for hospitalized patients and probably twice as high if non-hospitalized patients are included. However, a few recent population-based studies reported a much higher rate (>700/100,000). A changing pattern of epidemiology has been found in high-income countries, related to a decrease in road-accident injuries in young adults, while conversely the proportion of falls has increased with population aging. ConclusionMild TBI is a major public health concern, the epidemiology of which has greatly changed in the last twenty years.

Gait Deviations Associated With Concussion: A Systematic Review.

Gait deviations resulting from concussion are important to consider in the diagnosis, treatment progression, and return to activity after a concussion. To identify quantifiable gait deviations associated with concussion across populations and time since injury. Six electronic databases were systematically searched from January 1974 to September 2016. Studies selected included original data, had an analytic design, and reported a quantifiable gait parameter in individuals who had sustained a concussion as defined by the American Congress of Rehabilitation Medicine or related definitions. Preferred Reporting Items for Systematic reviews and Meta-Analysis guidelines were followed. Two independent authors assessed study quality [Downs and Black (DB) criteria] and level of evidence (Oxford Center of Evidence-Based Medicine Model). Of 2650 potentially relevant articles, 21 level 4 studies were included. The median DB score was 12/33 (range 10-16). Heterogeneity in gait parameters and timing of postconcussion testing precluded meta-analysis. There is consistent level 4 evidence of increased medial-lateral center-of-mass displacement, and inconsistent level 4 evidence of decreased gait velocity after concussion. Further, there is preliminary level 4 evidence that gait deficits may exist beyond the typical 10-day recovery period and return to activity. These findings suggest that individuals who have suffered a concussion may sway more in the frontal plane, and walk slower compared to healthy controls. Consensus about the most important gait parameters for concussion diagnosis and clinical management are lacking. Further, high-quality prospective cohort studies evaluating changes in gait from time of concussion to return to activity, sport, recreation and/or work are needed.

Minimum Competency Recommendations for Programs That Provide Rehabilitation Services for Persons With Disorders of Consciousness: A Position Statement of the American Congress of Rehabilitation Medicine and the National Institute on Disability, Independent Living and Rehabilitation Research Traumatic Brain Injury Model Systems

Persons who have disorders of consciousness (DoC) require care from multidisciplinary teams with specialized training and expertise in management of the complex needs of this clinical population. The recent promulgation of practice guidelines for patients with prolonged DoC by the American Academy of Neurology, American Congress of Rehabilitation Medicine (ACRM), and National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) represents a major advance in the development of care standards in this area of brain injury rehabilitation. Implementation of these practice guidelines requires explication of the minimum competencies of clinical programs providing services to persons who have DoC. The Brain Injury Interdisciplinary Special Interest Group of the ACRM, in collaboration with the Disorders of Consciousness Special Interest Group of the NIDILRR-Traumatic Brain Injury Model Systems convened a multidisciplinary panel of experts to address this need through the present position statement. Content area-specific workgroups reviewed relevant peer-reviewed literature and drafted recommendations which were then evaluated by the expert panel using a modified Delphi voting process. The process yielded 21 recommendations on the structure and process of essential services required for effective DoC-focused rehabilitation, organized into 4 categories: diagnostic and prognostic assessment (4 recommendations), treatment (11 recommendations), transitioning care/long-term care needs (5 recommendations), and management of ethical issues (1 recommendation). With few exceptions, these recommendations focus on infrastructure requirements and operating procedures for the provision of DoC-focused neurorehabilitation services across subacute and postacute settings.

Growing Academic Physiatry: The Comparative Impact of Baruch Grants to Harvard Medical School and Columbia College of Physicians and Surgeons. Part I

Growing Academic Physiatry: The Comparative Impact of Baruch Grants to Harvard Medical School and Columbia College of Physicians and Surgeons. Part I

Investigating the incidence and magnitude of heterotopic ossification with and without joints involvement in patients with a limb fracture and mild traumatic brain injury

ObjectivesThis study seeks to evaluate the incidence rate of heterotopic ossification (HO) formation in patients afflicted by an isolated limb fracture (ILF) and a concomitant mild traumatic brain injury (mTBI). MethodsThe current study is an observational study including ILF patients with or without a concomitant mTBI recruited from an orthopedic clinic of a Level 1 Trauma Hospital. Patients were diagnosed with a mTBI according to the American Congress of Rehabilitation Medicine (ACRM) criteria. Radiographs taken on average 3 months post-trauma were analyzed separately by two distinct specialists for the presence of HO proximally to the fracture site (joints or extra joints). Both raters referred to Brooker's and Della's Valle's classification to establish signs of HO. First, analyses were conducted for the full sample. Secondly, a matched cohort was used in order to control for specific factors, namely age, sex, type of injury, and time elapsed between the accident and the analyzed radiograph. ResultsThe full sample included a total of 183 patients with an ILF (94 females; 47.5 years old), of which 50 had a concomitant mTBI and 133 without. Radiographic evidence of HO was significantly higher in patients with an ILF and a mTBI compared to ILF patients (X2 = 6.50; p = 0.01). The matched cohort consisted of 94 participants (i.e.; 47 patients from the ILF + mTBI group and 47 patients from the ILF group). Again, ILF + mTBI patients presented significantly higher rates of HO signs in comparison to ILF patients (X2 = 3.69; p = 0.04). Presence of HO was associated with prolonged delays to return to work (RTW) only in ILF + mTBI patients (F = 4.055; p = 0.05) but not in ILF patients (F = 0.823; p = 0.37). ConclusionsStudy findings suggest that rates of HO are significantly higher proximally to fracture sites when ILF patients sustain a concomitant mTBI, even after controlling for factors known to influence HO. Moreover, results show that HO is associated with a prolonged RTW only in ILF patients with a concomitant mTBI but not in ILF-only patients. The impact of mTBI on HO formation warrants further attention to detect early signs of HO, to identify shared physiopathological mechanisms and, ultimately, to design targeted therapies.

Practice guideline update recommendations summary: Disorders of consciousness: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology; the American Congress of Rehabilitation Medicine; and the National Institute on Disability, Independent Living, and Rehabilitation Research.

In this issue of Neurology, Dr. Salas and a team of sleep medicine and medical education experts representing 6 major academic centers report on the need for and value of a formal sleep medicine curriculum in medical school. Not only are sleep medicine disorders extraordinarily common—affecting 1 in 6 Americans, according to survey data—but they are strongly tied to a swath of other comorbid conditions, ranging from cardiovascular disease to synucleinopathies. The authors also acknowledge that a heightened awareness of sleep hygiene among medical trainees may improve their own wellness and attenuate physician burnout. Dr. Sethi expresses some reservation that additional curricula may only add to the burden imposed upon medical students during their neurology clerkship. Instead, Dr. Sethi writes, perhaps sleep medicine should be incorporated into trainee education at the residency level. In response, Dr. Strowd and colleagues acknowledge this barrier. They emphasize the importance of pre-clerkship and longitudinal exposure to sleep medicine in order to crystallize these clinical concepts. By enriching the medical school curriculum with dedicated sleep medicine training, the authors hope that evaluating patients with sleep disorders will no longer be a sudden awakening.

Exercise for improving outcomes after osteoporotic vertebral fracture.

Exercise for improving outcomes after osteoporotic vertebral fracture.

Reader response: Practice guideline update recommendations summary: Disorders of consciousness: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology; the American Congress of Rehabilitation Medicine; and the National Institute on Disability, Independent Living, and Rehabilitation Research

We read with interest the disorders of consciousness guideline1 but found issues with the recommendations. Some of the recommendations are classified as level A (recommendations 3, 9, and 11). For example, “When prognosis is poor, long-term care must be discussed (level A)….”1 The references cited did not come from a randomized control trial.

Editors' note: Practice guideline update recommendations summary: Disorders of consciousness: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology; the American Congress of Rehabilitation Medicine; and the National Institute on Disability, Independent Living, and Rehabilitation Research

In their American Academy of Neurology (AAN) practice parameter, Giacino et al. provided a thorough review of the available evidence pertaining to the care of patients with impaired consciousness. The expert panel provided level of recommendations (LORs) regarding the discussion of long-term care needs, pain management strategies, and techniques for neuroprognostication in patients with disorders of consciousness. In response to these consensus recommendations, Phan et al. highlight 1 potential limitation of the LOR classification system that was used. Historically, the highest LOR (level A) was afforded only to recommendations based on 1 or more randomized clinical trials. However, this requirement was amended by the Institute of Medicine in 2011 as well as the 2011 AAN Clinical Guideline Practice Manual, as the authors emphasize in their response. After 2011, a level A recommendation was permitted as long as there was strong and consistent related evidence and inferences could be drawn. Therefore, a higher LOR could be assigned to recommendations with less explicit substantiation from large randomized clinical trials. By using this classification schema, some recommendations may be generalized to patients who are likely to benefit from such guidance. In their American Academy of Neurology (AAN) practice parameter, Giacino et al. provided a thorough review of the available evidence pertaining to the care of patients with impaired consciousness. The expert panel provided level of recommendations (LORs) regarding the discussion of long-term care needs, pain management strategies, and techniques for neuroprognostication in patients with disorders of consciousness. In response to these consensus recommendations, Phan et al. highlight 1 potential limitation of the LOR classification system that was used. Historically, the highest LOR (level A) was afforded only to recommendations based on 1 or more randomized clinical trials. However, this requirement was amended by the Institute of Medicine in 2011 as well as the 2011 AAN Clinical Guideline Practice Manual, as the authors emphasize in their response. After 2011, a level A recommendation was permitted as long as there was strong and consistent related evidence and inferences could be drawn. Therefore, a higher LOR could be assigned to recommendations with less explicit substantiation from large randomized clinical trials. By using this classification schema, some recommendations may be generalized to patients who are likely to benefit from such guidance.