Chronic Postconcussion Symptoms Research Articles

346 Multimodal assessment of sleep in individuals with chronic post-concussive symptoms: A Pilot Study

OBJECTIVES/GOALS: Weaimed to compare subjective and objective sleep in individuals with chronic post-concussive symptoms. We hypothesized an association between self-reported sleep quality and objective sleep parameters, which is different for concussed and control cohorts. METHODS/STUDY POPULATION: 28 individuals with chronic post-concussive symptoms and 13 age-matched controls (no concussion history) completed the ISI, PSQI, PROMIS Depression, Anxiety, Stress and Cognitive questionnaires at enrollment. Objective sleep parameters were obtained for a minimum of 7 days and up to 30 days with a validated sleep monitoring device placed under the subject’s bed (Emfit). For each night, raw activity data per minute were analyzed to determinein-bed, sleep, wake, andout-of-bedtimes. These measures were used to calculate total sleep time (TST), sleep onset latency (SOL), and wake after sleep onset (WASO) for each night. RESULTS/ANTICIPATED RESULTS: Concussed individuals reported worse sleep with PSQI and ISI scores significantly higher than controls. They also showedsignificant associations between PSQI and Dep ression, ISI and Depression, and ISI and Anxiety scores. There was no difference between objective sleep parameters in the concussed and control cohorts (in-bed/sleep/wake/out-of-bed times, TST, SOL, and WASO). Instead, higher PSQI, ISI, Depression, Anxiety, and Stress scores (greater symptom burden) were all associated with later sleep times, where as higher Cognitive scores (greater cognitive function) were associated with earlier sleep times, regardless of group status. DISCUSSION/SIGNIFICANCE: Concussed individuals report worse subjective sleep but no differences to controls when objectively assessing sleep. Depression/anxiety, and not concussion status, determine objective sleep parameters. Psychiatric comorbidities should inform the treatment of post-concussive sleep disturbances.

A mouse model of repeated traumatic brain injury-induced hearing impairment: Early cochlear neurodegeneration in the absence of hair cell loss

PurposeTraumatic Brain Injury (TBI) is a major cause of death and disability worldwide. Mounting evidence suggests that even mild TBI injuries, which comprise >75% of all TBIs, can cause chronic post-concussive neurological symptoms, especially when experienced repetitively (rTBI). The most common post-concussive symptoms include auditory dysfunction in the form of hearing loss, tinnitus, or impaired auditory processing, which can occur even in the absence of direct damage to the auditory system at the time of injury. The mechanism by which indirect damage causes loss of auditory function is poorly understood, and treatment is currently limited to symptom management rather than preventative care. We reasoned that secondary injury mechanisms, such as inflammation, may lead to damage of the inner ear and parts of the brain used for hearing after rTBI. Herein, we established a model of indirect damage to the auditory system induced by rTBI and characterized the pathology of hearing loss. MethodsWe established a mouse model of rTBI in order to determine a timeline of auditory pathology following multiple mild injuries. Mice were subject to controlled cortical impact at the skull midline once every 48 h, for a total of 5 hits. Auditory function was assessed via the auditory brainstem response (ABR) at various timepoints post injury. Brain and cochleae were collected to establish a timeline of cellular pathology. ResultsWe observed increased ABR thresholds and decreased (ABR) P1 amplitudes in rTBI vs sham animals at 14 days post-impact (dpi). This effect persisted for up to 60 days (dpi). Auditory temporal processing was impaired beginning at 30 dpi. Spiral ganglion degeneration was evident at 14 dpi. No loss of hair cells was detected at this time, suggesting that neuronal loss is one of the earliest notable events in hearing loss caused by this type of rTBI. ConclusionsWe conclude that rTBI results in chronic auditory dysfunction via damage to the spiral ganglion which occurs in the absence of any reduction in hair cell number. This suggests early neuronal damage that may be caused by systemic mechanisms similar to those leading to the spread of neuronal death in the brain following TBI. This TBI-hearing loss model provides an important first step towards identifying therapeutic targets to attenuate damage to the auditory system following head injury.

Multispectral optoacoustic tomography (MSOT): Monitoring neurovascular changes in a mouse repetitive traumatic brain injury model

BackgroundEvidence suggests that mild TBI injuries, which comprise > 75% of all TBIs, can cause chronic post-concussive symptoms, especially when experienced repetitively (rTBI). rTBI is a major cause of cognitive deficit in athletes and military personnel and is associated with neurovascular changes. Current methods to monitor neurovascular changes in detail are prohibitively expensive and invasive for patients with mild injuries. New MethodWe evaluated the potential of multispectral optoacoustic tomography (MSOT) to monitor neurovascular changes and assess therapeutic strategies in a mouse model of rTBI. Mice were subjected to rTBI or sham via controlled cortical impact and administered pioglitazone (PG) or vehicle. Oxygenated and deoxygenated hemoglobin were monitored using MSOT. Indocyanine green clearance was imaged via MSOT to evaluate blood-brain-barrier (BBB) integrity. ResultsMice subjected to rTBI show a transient increase in oxygenated/total hemoglobin ratio which can be mitigated by PG administration. rTBI mice also show BBB disruption shortly after injury and reduction of oxygenated/total hemoglobin in the chronic stage, neither of which were affected by PG intervention. Comparison with existing methodsMSOT imaging has the potential as a noninvasive in vivo imaging method to monitor neurovascular changes and assess therapeutics in mouse models of rTBI. In comparison to standard methods of tracking inflammation and BBB disruption, MSOT can be used multiple times throughout the course of injury without the need for surgery. Thus, MSOT is especially useful in research of rTBI models for screening therapeutics, and with further technological improvements may be extended for use in rTBI patients.

Acute thalamic connectivity precedes chronic post-concussive symptoms in mild traumatic brain injury.

Chronic post-concussive symptoms are common after mild traumatic brain injury (mTBI) and are difficult to predict or treat. Thalamic functional integrity is particularly vulnerable in mTBI and may be related to long-term outcomes but requires further investigation. We compared structural MRI and resting state functional MRI in 108 patients with a Glasgow Coma Scale (GCS) of 13-15 and normal CT, and 76 controls. We examined whether acute changes in thalamic functional connectivity were early markers for persistent symptoms and explored neurochemical associations of our findings using PET data. Of the mTBI cohort, 47% showed incomplete recovery 6 months post-injury. Despite the absence of structural changes, we found acute thalamic hyperconnectivity in mTBI, with specific vulnerabilities of individual thalamic nuclei. Acute fMRI markers differentiated those with chronic post-concussive symptoms, with time- and outcome-dependent relationships in a sub-cohort followed longitudinally. Moreover, emotional and cognitive symptoms were associated with changes in thalamic functional connectivity to known serotonergic and noradrenergic targets, respectively. Our findings suggest that chronic symptoms can have a basis in early thalamic pathophysiology. This may aid identification of patients at risk of chronic post-concussive symptoms following mTBI, provide a basis for development of new therapies and facilitate precision medicine application of these therapies.

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.

Memory for forgetting in adults with persistent symptoms following concussion

ABSTRACT Introduction Persistent memory complaints following concussion often do not coincide with evidence of objective memory impairment. To the extent this clinical presentation represents Functional Cognitive Disorder (FCD), we would expect preservation or even enhancement of memory for instances of forgetting, based on two lines of prior evidence. First, emotional arousal enhances autobiographical memory. People who experience memory lapses as worrisome may better remember them. Second, individuals with FCD can paradoxically provide detailed accounts of memory lapses compared to patients with neurodegenerative disease, who tend to provide vague examples. The current study aimed to better characterize the recall of forgetting events in people with subjective memory problems following concussion. Methods The study sample consisted of adults with chronic post-concussion symptoms (N = 37, M = 42.7 years old; 70.27% women; M = 24.9 months post-injury) and normal-range performance on conventional neuropsychological tests. Participants completed a measure of memory complaint severity and the Autobiographical Interview (AI). The AI was used to quantify the richness of narrative recollections of recent instances when they forgot something and (control) personal events that did not involve forgetting. Linear regression modeling assessed the relationship between memory complaint severity and AI variables, including narrative details, valence, arousal, and rehearsal of memories. Results There was no association between memory complaint severity and memory for forgetting vs. control events. We further found no association between memory complaint severity and AI performance overall (collapsing across forgetting and control events). Participants with greater memory complaints experienced past memory lapses as more negative than control memories, but did not consistently differ on other AI phenomenological variables. Conclusion Autobiographical recall of memory lapses appears preserved but not selectively heightened in people who report experiencing severe memory problems long after concussion. This inconsistency supports conceptualization of persistent memory complaints after concussion as FCD.

Rehabilitation of Persistent Symptoms and Neurocognitive Deficits Following Sports-Related Concussion in a Professional Hockey Player: Case Study

To demonstrate decreased post-concussive symptomatology and neurocognitive improvements in a professional hockey player following a multimodal, functional neurology approach to neurorehabilitation. Hockey is one of the top 3 sports in which concussions occur and has one of the top 10 highest participation numbers of sports in the northern hemisphere. The investigation of treatment modalities is warranted given the prevalence of hockey throughout society. This case study presents a 31-year-old male professional hockey athlete who had sustained 5 diagnosed concussions with additional suspected concussions throughout his career. His symptoms remained after independently receiving physical therapy and vestibular rehabilitation, causing an inability to continue playing hockey at a professional level. The patient was prescribed 10 treatment sessions over 5 contiguous days at an outpatient neurorehabilitation center specializing in functional neurology. The C3Logix neurocognitive assessment and graded symptom checklist were utilized at intake and discharge. Multimodal treatment interventions included transcranial photobiomodulation, non-invasive neuromodulation of the lingual branch of the trigeminal nerve, hand-eye coordination training, vestibular rehabilitation utilizing a three-axis whole-body off-axis rotational device, and cognitive training. On intake, their composite symptom score was reported as 16/162, Trail Making Test Part B was 24.1 seconds, Simple Reaction Time was 274 milliseconds, and Choice Reaction Time was 496 milliseconds. On discharge, the patient experienced an 81% in self-reported symptoms, Trail Making Test Part B improved to 17 seconds (+29.46%), Simple Reaction Time was 252 milliseconds (8% faster), and Choice Reaction Time was 465 milliseconds (24% faster). The present case study results demonstrated meaningful improvements in both self-rated concussion symptoms and neurocognitive performance for this patient. The Press suggest further investigation into functional neurology-based, multimodal, intensive approaches to decrease chronic post-concussion symptoms and improve neurocognitive performance in athletes that engage in hockey.

Effective connectivity in the default mode network after paediatric traumatic brain injury.

Children who experience a traumatic brain injury (TBI) are at elevated risk for a range of negative cognitive and neuropsychological outcomes. Identifying which children are at greatest risk for negative outcomes can be difficult due to the heterogeneity of TBI. To address this barrier, the current study applied a novel method of characterizing brain connectivity networks, Bayesian multi-subject vector autoregressive modelling (BVAR-connect), which used white matter integrity as priors to evaluate effective connectivity-the time-dependent relationship in functional magnetic resonance imaging (fMRI) activity between two brain regions-within the default mode network (DMN). In a prospective longitudinal study, children ages 8-15 years with mild to severe TBI underwent diffusion tensor imaging and resting state fMRI 7weeks after injury; post-concussion and anxiety symptoms were assessed 7months after injury. The goals of this study were to (1) characterize differences in positive effective connectivity of resting-state DMN circuitry between healthy controls and children with TBI, (2) determine if severity of TBI was associated with differences in DMN connectivity and (3) evaluate whether patterns of DMN effective connectivity predicted persistent post-concussion symptoms and anxiety. Healthy controls had unique positive connectivity that mostly emerged from the inferior temporal lobes. In contrast, children with TBI had unique effective connectivity among orbitofrontal and parietal regions. These positive orbitofrontal-parietal DMN effective connectivity patterns also differed by TBI severity and were associated with persisting behavioural outcomes. Effective connectivity may be a sensitive neuroimaging marker of TBI severity as well as a predictor of chronic post-concussion symptoms and anxiety.

Vergence, accommodation, and visual tracking in children and adolescents evaluated in a multidisciplinary concussion clinic

Many patients with concussion experience visual symptoms following injury that lead to a diagnosis of convergence insufficiency, accommodative insufficiency, or saccadic dysfunction. However, these diagnostic categories are based on aggregates of clinical tests developed from a non-concussed population and therefore may not accurately describe visual deficits in the concussed population. Thus, we sought to understand individual metrics of visual dysfunction in chronically symptomatic post-concussion patients. This retrospective cross-sectional study included patients examined at the multidisciplinary concussion clinic (MDCC) at Boston Children’s Hospital over four years. Patients aged 5–21 years who had a complete assessment of eye alignment, vergence, accommodation, and visual tracking, and had visual acuity better than or equal to 20/30 in each eye were included. Patients with history of amblyopia, strabismus, or ocular pathology were excluded. Chart review yielded 116 patients who met inclusion criteria (median age 15 years, 64% female). The majority of patients (52%) experienced a single concussion and most were sports-related (50%). Clinical data show vergence, accommodation, or visual tracking deficits in 95% of patients. A receded near point of convergence (NPC, 70/116) and reduced accommodative amplitude (63/116) were the most common deficits. Both NPC and accommodative amplitude were significantly correlated with one another (r = −0.5) and with measures of visual tracking (r = −0.34). Patients with chronic post-concussion symptoms show deficits in individual metrics of vergence, accommodation and visual tracking. The high incidence of these deficits, specifically NPC and accommodative amplitude, highlights the need for a detailed sensorimotor evaluation to guide personalized treatment following concussion.

Association of Sex and Age With Mild Traumatic Brain Injury–Related Symptoms: A TRACK-TBI Study

Knowledge of differences in mild traumatic brain injury (mTBI) recovery by sex and age may inform individualized treatment of these patients. To identify sex-related differences in symptom recovery from mTBI; secondarily, to explore age differences within women, who demonstrate poorer outcomes after TBI. The prospective cohort study Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) recruited 2000 patients with mTBI from February 26, 2014, to July 3, 2018, and 299 patients with orthopedic trauma (who served as controls) from January 26, 2016, to July 27, 2018. Patients were recruited from 18 level I trauma centers and followed up for 12 months. Data were analyzed from August 19, 2020, to March 3, 2021. Patients with mTBI (defined by a Glasgow Coma Scale score of 13-15) triaged to head computed tomography in 24 hours or less; patients with orthopedic trauma served as controls. Measured outcomes included (1) the Rivermead Post Concussion Symptoms Questionnaire (RPQ), a 16-item self-report scale that assesses postconcussion symptom severity over the past 7 days relative to preinjury; (2) the Posttraumatic Stress Disorder Checklist for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (PCL-5), a 20-item test that measures the severity of posttraumatic stress disorder symptoms; (3) the Patient Health Questionnaire-9 (PHQ-9), a 9-item scale that measures depression based on symptom frequency over the past 2 weeks; and (4) the Brief Symptom Inventory-18 (BSI-18), an 18-item scale of psychological distress (split into Depression and Anxiety subscales). A total of 2000 patients with mTBI (1331 men [67%; mean (SD) age, 41.0 (17.3) years; 1026 White (78%)] and 669 women [33%; mean (SD) age, 43.0 (18.5) years; 505 (76%) White]). After adjustment of multiple comparisons, significant TBI × sex interactions were observed for cognitive symptoms (B = 0.76; 5% false discovery rate-corrected P = .02) and somatic RPQ symptoms (B = 0.80; 5% false discovery rate-corrected P = .02), with worse symptoms in women with mTBI than men, but no sex difference in symptoms in control patients with orthopedic trauma. Within the female patients evaluated, there was a significant TBI × age interaction for somatic RPQ symptoms, which were worse in female patients with mTBI aged 35 to 49 years compared with those aged 17 to 34 years (B = 1.65; P = .02) or older than 50 years (B = 1.66; P = .02). This study found that women were more vulnerable than men to persistent mTBI-related cognitive and somatic symptoms, whereas no sex difference in symptom burden was seen after orthopedic injury. Postconcussion symptoms were also worse in women aged 35 to 49 years than in younger and older women, but further investigation is needed to corroborate these findings and to identify the mechanisms involved. Results suggest that individualized clinical management of mTBI should consider sex and age, as some women are especially predisposed to chronic postconcussion symptoms even 12 months after injury.

Accelerated repetitive transcranial magnetic stimulation in the treatment of post-concussion symptoms due to mild traumatic brain injury: a pilot study

ABSTRACT Objective: To investigate the feasibility, tolerability, and efficacy of twice-daily, low frequency (LF) repetitive transcranial magnetic stimulation (rTMS) over the right dorsolateral prefrontal cortex (DLPFC) in the reduction of chronic post-concussion symptoms (PCS) in patients who have suffered a mild traumatic brain injury (mTBI). Methods: 15 patients with mTBI received 30 sessions of twice-daily LF rTMS (1 Hz) over the right DLPFC. Post-concussion symptoms, pain, disability, fatigue, apathy, agitation, and mood were assessed by a psychiatrist pre- and post-treatment. Cognitive testing was also performed pre-, mid-, and post-rTMS. Results: All participants completed treatment with no serious adverse events. Significant improvements were observed in overall post-concussion symptoms, disability and pain ratings, as well as depression and anxiety symptoms. There was no significant change in overall executive functioning, fatigue severity, apathy, or agitation. Cognitive testing revealed improvements in verbal fluency, working memory, selective attention, and cognitive processing speed. Conclusions: This small-sample pilot study suggests that twice-daily, LF rTMS over the right DLPFC can be safely and tolerably applied and has the potential to improve post-concussion symptoms as well as elements of mood and cognition in patients with mTBI. Larger, sham-controlled studies will be important to confirm these observations.

Post-acute white matter microstructure predicts post-acute and chronic post-concussive symptom severity following mild traumatic brain injury in children.

IntroductionMild traumatic brain injury (TBI) is a global public health concern that affects millions of children annually. Mild TBI tends to result in subtle and diffuse alterations in brain tissue, which challenges accurate clinical detection and prognostication. Diffusion tensor imaging (DTI) holds promise as a diagnostic and prognostic tool, but little research has examined DTI in post-acute mild TBI. The current study compared post-acute white matter microstructure in children with mild TBI versus those with mild orthopedic injury (OI), and examined whether post-acute DTI metrics can predict post-acute and chronic post-concussive symptoms (PCS).Materials and methodsChildren aged 8–16.99 years with mild TBI (n = 132) or OI (n = 69) were recruited at emergency department visits to two children's hospitals, during which parents rated children's pre-injury symptoms retrospectively. Children completed a post-acute (<2 weeks post-injury) assessment, which included a 3T MRI, and 3- and 6-month post-injury assessments. Parents and children rated PCS at each assessment. Mean diffusivity (MD) and fractional anisotropy (FA) were derived from diffusion-weighted MRI using Automatic Fiber Quantification software. Multiple multivariable linear and negative binomial regression models were used to test study aims, with False Discovery Rate (FDR) correction for multiple comparisons.ResultsNo significant group differences were found in any of the 20 white matter tracts after FDR correction. DTI metrics varied by age and sex, and site was a significant covariate. No interactions involving group, age, and sex were significant. DTI metrics in several tracts robustly predicted PCS ratings at 3- and 6-months post-injury, but only corpus callosum genu MD was significantly associated with post-acute PCS after FDR correction. Significant group by DTI metric interactions on chronic PCS ratings indicated that left cingulum hippocampus and thalamic radiation MD was positively associated with 3-month PCS in the OI group, but not in the mild TBI group.ConclusionsPost-acute white matter microstructure did not differ for children with mild TBI versus OI after correcting for multiple comparisons, but was predictive of post-acute and chronic PCS in both injury groups. These findings support the potential prognostic utility of this advanced DTI technique.

B-48 Effects of Anxiety on Response to a Subsymptom Threshold Exercise Program for Treatment of Persistent Post-Concussive Symptoms: A Pilot Randomized Clinical Trial

Abstract Objective There is a growing literature to support the use of subsymptom threshold exercise for treatment of both acute and chronic post-concussion symptoms. The present study aimed to explore the influence of anxiety on response to exercise intervention for patients with persistent post-concussive symptoms. Methods Sixteen adolescents (ages 14-18) with persistent (&gt;1 month) concussion symptoms were randomized into a light, home exercise group and a subsymptom threshold exercise group performed by PT’s (modeled after Leddy et al.,2019). Participants underwent intervention for 6 weeks and completed evaluations at Baseline, Mid-Point, and Follow-up after treatment; evaluations included State-Trait Anxiety Inventory (STAI), the Post-Concussive Scale-Revised (PCS-R), as well as additional measures of emotional functioning, balance disturbance, and neuropsychological functioning. Results Average PCS-R endorsement improved by 21 points from Baseline to Follow-up across treatment groups (PCS-R Total Change M = -21.29,SD = 13.54). There were meaningful Baseline differences between intervention groups in STAI state anxiety (p &lt; .05) and STAI trait anxiety (p = 0.51); STAI variables were used as covariates in an ANOVA comparing mean PCS-R Percent Change between treatment and control groups. After removing the influence of anxiety, the intervention groups significantly differed and showed large effect (F(3,13) = 6.94,p &lt; .05,partial eta2 = .41), with the intervention group improving (PCS-R Percent Change M = -63.3,SD = 17.4) more than the control group (PCS-R Percent Change M = -56.8,SD = 27.8). Conclusion Exercise intervention appears to be more effective than standard-of-care light activity in the treatment of persistent symptoms in adolescents; however, anxiety may alter response to intervention. Complimentary mental health treatment may augment response to exercise intervention and optimize concussion recovery trajectory in patients with persisting symptoms.

The Role of Potentially Malleable Factors in Post-Concussive Symptoms and Objective Cognitive Outcomes in Iraq and Afghanistan Veterans with History of Mild TBI

Abstract Objective We examined whether potentially malleable factors are associated with post-concussive symptoms (PCS) and cognition in Veterans with mild traumatic brain injury (mTBI) histories. Method Combat-exposed Iraq and Afghanistan Veterans with remote history of mTBI (N=48) completed a neuropsychological assessment and self-report questionnaires. Hierarchical linear regressions predicting PCS (Rivermead Post-Concussion Symptoms Questionnaire) and objective cognition included relevant demographic, injury, and psychiatric symptom variables in the first block and five malleable factors (TBI knowledge, self-efficacy, coping style, attribution of symptoms to mTBI, and uncommonly-endorsed symptoms [mild Brain Injury Atypical Symptoms (mBIAS) scale]) in the second block. Those with valid performance validity tests (n = 42) were included in the cognitive test analyses. Results With psychiatric symptoms and lifetime history of mTBIs entered first, malleable factors accounted for 14-17% of additional variance in PCS (p &lt; .001). Lower self-efficacy (B = -.53, p &lt; .001) and greater attribution of symptoms to mTBI (B = .21, p = .05) were associated with higher PCS, whereas an approach style of coping, TBI knowledge, and the mBIAS were not (p’s&gt;.05). Regarding cognition, the malleable factors block accounted for 25% of additional variance in executive functioning (p = .04) with premorbid intelligence entered first. Specifically, higher mBIAS scores significantly predicted worse executive functioning (B = -.50, p = .004). No significant associations emerged when predicting attention/processing speed or memory (p’s&gt;.05). Conclusions In combat-exposed Veterans with mTBI histories, potentially malleable factors contribute to clinical outcomes even after accounting for psychiatric symptoms. These malleable features are prime targets to augment during psychoeducation (e.g., uncommonly-endorsed symptoms, attribution of symptoms) and cognitive behavioral therapy (e.g., self-efficacy) in the context of chronic PCS.

Impaired auditory processing and neural representation of speech in noise among symptomatic post-concussion adults

ABSTRACTBackground: The purpose of the study was to examine auditory event-related potential (AERP) evidence of changes in earlier and later stages of auditory processing in individuals with long-term post-concussion problems compared to healthy controls, with a secondary aim of comparing AERPs by functional auditory behavioral outcomes.Methods: P1-N1-P2 complex and P300 components recorded to speech in quiet and background noise conditions were completed in individuals with ongoing post-concussion symptoms following mTBI and healthy controls. AERPs were also examined between sub-groups with normal or impaired auditory processing by behavioral tests.Results: Group differences were present for later stages of auditory processing (P300). Earlier components did not significantly differ by group overall but were more affected by noise in the mTBI group. P2 amplitude in noise differed between mTBI sub-groups with normal or impaired auditory processing.Conclusion: AERPs revealed differences between healthy controls and those with chronic post-concussion symptoms following mTBI at a later stage of auditory processing (P300). Neural processing at the earlier stage (P1-N1-P2) was more affected by noise in the mTBI group. Preliminary evidence suggested that it may be only the proportion of individuals with functional evidence of central auditory dysfunction with changes in AERPs at earlier stages of processing.

Auditory and Cognitive Behavioral Performance Deficits and Symptom Reporting in Postconcussion Syndrome Following Mild Traumatic Brain Injury.

Purpose This study examined auditory deficits and symptom reporting in individuals with long-term postconcussion symptoms following a single mild traumatic brain injury (mTBI) compared to age- and gender-matched controls without a history of mTBI. Method Case history interviews, symptom questionnaires, and a battery of central auditory and neuropsychological tests were administered to 2 groups. The mTBI group was a civilian population recruited from a local concussion management program who were seeking rehabilitation for postconcussion-related problems in a postacute period between 3 and 18 months following injury. Symptom validity testing was included to assess the rate of possible insufficient test effort and its influence on scores for all outcome measures. Analyses of group differences in test scores were performed both with and without the participants who showed insufficient test effort. Rates of symptom reporting, correlations among symptoms and behavioral test outcomes, and the relationships between auditory and cognitive test performance were analyzed. Results The mTBI group reported a high rate of auditory symptoms and general postconcussion symptoms. Performance on neuropsychological tests of cognitive function showed some differences in raw scores between groups, but when effort was considered, there were no significant differences in the rate of abnormal performance between groups. In contrast, there were significant differences in both raw scores and the rate of abnormal performance between groups for some auditory tests when only considering participants with sufficient effort. Auditory symptoms were strongly correlated with other general postconcussion symptoms. Conclusions Significant auditory symptoms and evidence of long-term central auditory dysfunction were found in a subset of individuals who had chronic postconcussion symptoms after a single mTBI unrelated to blast trauma. The rate of abnormal performance on auditory behavioral tests exceeded the rate of abnormal performance on tests of cognitive function. Supplemental Material https://doi.org/10.23641/asha.8329955.

Postconcussion: Receded Near Point of Convergence is not Diagnostic of Convergence Insufficiency

To determine the frequency of occurrence of receded near point of convergence (NPC) in patients with chronic concussion-related symptoms and in those with receded NPC to enumerate the frequency of convergence insufficiency and other oculomotor disorders. Retrospective cross-sectional study. Clinic charts were retrospectively reviewed for the prior 3.5 years to identify all patients < 21 years old who were > 28days postconcussion, had chronic concussion-related symptoms, had normal visual acuity, and had received a comprehensive sensorimotor examination. The frequency of receded NPC and oculomotor diagnoses were determined. Of the 83 eligible patients, 74 (89%) had receded NPC. Of these, 70 (95%) had oculomotor disorders; 30 (41%) had disorders of accommodation only; 21 (28%) had convergence insufficiency and accommodation deficits; and 6 (8%) had convergence insufficiency only. Six (8%) had a convergence deficit other than convergence insufficiency (all with concurrent accommodative disorders); 4 (5%) had both a nonspecific vergence dysfunction and accommodation deficits; 2 (3%) had convergence excess only; and 1 (1%) had both convergence excess and accommodative deficits. A receded NPC was present in the majority of young patients with chronic postconcussion symptoms. Associated with numerous underlying oculomotor dysfunctions, the clinical finding of a receded NPC is not synonymous with the diagnosis of convergence insufficiency. Because treatment options for the various oculomotor dysfunctions differ, it is prudent that these patients undergo a thorough examination of their vergence and accommodative systems so that an accurate diagnosis can be made and appropriate treatment prescribed.

Reconceptualizing rehabilitation of individuals with chronic symptoms following mild traumatic brain injury.

Effective treatment for postconcussive symptoms (PCS) immediately following mild traumatic brain injury (mTBI) includes reassurance, support, education about mTBI, and symptom management. However, effective treatments for chronic postconcussive-like symptoms, particularly with mental health comorbidities, remain unclear. Research Method/Design: We conduct a critical review of the treatment literature for chronic PCS, present exemplar studies of two alternative treatment approaches (i.e., cognitive rehabilitation (CR) and psychotherapy with various cognitive-behavioral therapy (CBT) approaches) and compare their relative effectiveness, and examine other literature to compare treatment benefits of one approach over another. This review and comparisons found CBT approaches to be 5 to 6 times more potent in reducing chronic PCS than CR. Based on these findings we encourage rehabilitation professionals to "re-conceptualize" the factors that likely underlie chronic PCS and the most effective treatment for this condition. We propose that CBT interventions focusing on comorbid and underlying mental health issues should be an essential, not adjunctive, treatment approach for chronic PCS. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

CLINICAL NUTRITION AND MULTIMODAL NEUROREHABILITATION IMPROVE CHRONIC POST-CONCUSSION SYMPTOMS IN 22 YEAR OLD WOMAN

Event Abstract Back to Event CLINICAL NUTRITION AND MULTIMODAL NEUROREHABILITATION IMPROVE CHRONIC POST-CONCUSSION SYMPTOMS IN 22 YEAR OLD WOMAN David J. Clark1* 1 Carrick Institute, United States Background: A 22 year old woman presented with a 5 month history of fatigue, forgetfulness, difficulty concentrating, depression, irritability, light and sound sensitivity, dizziness/motion sickness, problems with balance and depth perception subsequent to a motor vehicle accident. She was on medical leave from University. Prior to presentation she had completed some vision therapy and primitive reflex remediation that worsened her symptoms. At time of prevention she was following a gluten-free, vegan diet. She was taking B12, Vitamin D, MCT oil, flax, ginkgo biloba and magnesium. Methods: Neurological examination revealed decreased left arm swing that improved with dual-tasking, horizontal and vertical pursuit testing at bedside elicited excessive sway, slowed vertical saccades tested at bedside, vertical saccades tested with VOG showed marked hypometria downwards and average latency greater than 200 ms, vertical optokinetics tested with VOG showed low gain in both directions, drowsiness and hippus during the VOG assessment. Ingestion of Th1 and Th2 boosters provoked her symptoms. Laboratory examination revealed low ferritin (8 ng/mL), clinically significantly low LDH (119 IU/L) , folate (10.7 ng/mL), magnesium (1.9 mg/dL). Initially, her diet was modified to increase her total protein and calorie intake, as well as the frequency of calorie intake. She was placed on supplemental folate, iron, turmeric, resveratrol, vitamin, magnesium, and a multi-nutrient to support normal tissue glucose levels. After 5 months of this program she was enrolled in a 4 day multi-modal neurorehabilitation program utilizing active gaze stabilization, Interactive Metronome, proprioceptive exercises, progressive balance exercises, and coupled reduction manipulation. Results: Due to improvement in her original presenting complaints, 2 months after her finishing her initial program, she re-enrolled in University. At last follow up she reported only some difficulty in cognitive set shifting. She continued to take Vitamin D, folate, iron, and the multi-nutrient formula to support normal tissue glucose levels. Conclusion: The author suggests further investigation into comprehensive, multimodal forms of neurorehabilitation and clinical nutrition in the treatment of chronic post-concussion symptoms. Keywords: post concussion syndrome (PCS), Neurorehabilitation, Clinical Nutrition, supplementation, Anti-inflammatory diet Conference: International Symposium on Clinical Neuroscience, Orlando, United States, 24 May - 26 May, 2019. Presentation Type: Poster Presentation Topic: Clinical Neuroscience Citation: Clark DJ (2019). CLINICAL NUTRITION AND MULTIMODAL NEUROREHABILITATION IMPROVE CHRONIC POST-CONCUSSION SYMPTOMS IN 22 YEAR OLD WOMAN. Front. Neurol. Conference Abstract: International Symposium on Clinical Neuroscience. doi: 10.3389/conf.fneur.2019.62.00013 Copyright: The abstracts in this collection have not been subject to any Frontiers peer review or checks, and are not endorsed by Frontiers. They are made available through the Frontiers publishing platform as a service to conference organizers and presenters. The copyright in the individual abstracts is owned by the author of each abstract or his/her employer unless otherwise stated. Each abstract, as well as the collection of abstracts, are published under a Creative Commons CC-BY 4.0 (attribution) licence (https://creativecommons.org/licenses/by/4.0/) and may thus be reproduced, translated, adapted and be the subject of derivative works provided the authors and Frontiers are attributed. For Frontiers’ terms and conditions please see https://www.frontiersin.org/legal/terms-and-conditions. Received: 02 Apr 2019; Published Online: 27 Sep 2019. * Correspondence: Mx. David J Clark, Carrick Institute, Cape Canaveral, Florida, 32920, United States, mail@doctordavidclark.com Login Required This action requires you to be registered with Frontiers and logged in. To register or login click here. Abstract Info Abstract The Authors in Frontiers David J Clark Google David J Clark Google Scholar David J Clark PubMed David J Clark Related Article in Frontiers Google Scholar PubMed Abstract Close Back to top Javascript is disabled. Please enable Javascript in your browser settings in order to see all the content on this page.

Enhancing Self-Management of Chronic Post-Concussive Symptoms in a Military Setting

Enhancing Self-Management of Chronic Post-Concussive Symptoms in a Military Setting