The Sensor Technology and Rehabilitative Timing (START) Protocol: A Randomized Controlled Trial for the Rehabilitation of Mild Traumatic Brain Injury

BACKGROUND: Clinical practice for rehabilitation after mild traumatic brain injury (mTBI) is variable, and guidance on when to initiate physical therapy is lacking. Wearable sensor technology may aid clinical assessment, performance monitoring, and exercise adherence, potentially improving rehabilitation outcomes during unsupervised home exercise programs. OBJECTIVE: The objectives of this study were to: (1) determine whether initiating rehabilitation earlier than typical will improve outcomes after mTBI, and (2) examine whether using wearable sensors during a home-exercise program will improve outcomes in participants with mTBI. DESIGN: This was a randomized controlled trial. SETTING: This study will take place within an academic hospital setting at Oregon Health & Science University and Veterans Affairs Portland Health Care System, and in the home environment. PARTICIPANTS: This study will include 160 individuals with mTBI. INTERVENTION: The early intervention group (n = 80) will receive one-on-one physical therapy 8 times over 6 weeks and complete daily home exercises. The standard care group (n = 80) will complete the same intervention after a 6- to 8-week wait period. One-half of each group will receive wearable sensors for therapist monitoring of patient adherence and quality of movements during their home exercise program. MEASUREMENTS: The primary outcome measure will be the Dizziness Handicap Inventory score. Secondary outcome measures will include symptomatology, static and dynamic postural control, central sensorimotor integration posturography, and vestibular-ocular-motor function. LIMITATIONS: Potential limitations include variable onset of care, a wide range of ages, possible low adherence and/or withdrawal from the study in the standard of care group, and low Dizziness Handicap Inventory scores effecting ceiling for change after rehabilitation. CONCLUSIONS: If initiating rehabilitation earlier improves primary and secondary outcomes post-mTBI, this could help shape current clinical care guidelines for rehabilitation. Additionally, using wearable sensors to monitor performance and adherence may improve home exercise outcomes

Efficacy of tart cherry juice in reducing muscle pain during running: a randomized controlled trial

Abstract Background Long distance running causes acute muscle damage resulting in inflammation and decreased force production. Endurance athletes use NSAIDs during competition to prevent or reduce pain, which carries the risk of adverse effects. Tart cherries, rich in antioxidant and anti-inflammatory properties, may have a protective effect to reduce muscle damage and pain during strenuous exercise. This study aimed to assess the effects of tart cherry juice as compared to a placebo cherry drink on pain among runners in a long distance relay race. Methods The design was a randomized, double blind, placebo controlled trial. Fifty-four healthy runners (36 male, 18 female; 35.8 ± 9.6 yrs) ran an average of 26.3 ± 2.5 km over a 24 hour period. Participants ingested 355 mL bottles of tart cherry juice or placebo cherry drink twice daily for 7 days prior to the event and on the day of the race. Participants assessed level of pain on a standard 100 mm Visual Analog Scale (VAS) at baseline, before the race, and after the race. Results While both groups reported increased pain after the race, the cherry juice group reported a significantly smaller increase in pain (12 ± 18 mm) compared to the placebo group (37 ± 20 mm) (p Conclusions Ingesting tart cherry juice for 7 days prior to and during a strenuous running event can minimize post-run muscle pain.</p

Concussion As a Multi-Scale Complex System: An Interdisciplinary Synthesis of Current Knowledge

Traumatic brain injury (TBI) has been called “the most complicated disease of the most complex organ of the body” and is an increasingly high-profile public health issue. Many patients report long-term impairments following even “mild” injuries, but reliable criteria for diagnosis and prognosis are lacking. Every clinical trial for TBI treatment to date has failed to demonstrate reliable and safe improvement in outcomes, and the existing body of literature is insufficient to support the creation of a new classification system. Concussion, or mild TBI, is a highly heterogeneous phenomenon, and numerous factors interact dynamically to influence an individual’s recovery trajectory. Many of the obstacles faced in research and clinical practice related to TBI and concussion, including observed heterogeneity, arguably stem from the complexity of the condition itself. To improve understanding of this complexity, we review the current state of research through the lens provided by the interdisciplinary field of systems science, which has been increasingly applied to biomedical issues. The review was conducted iteratively, through multiple phases of literature review, expert interviews, and systems diagramming and represents the first phase in an effort to develop systems models of concussion. The primary focus of this work was to examine concepts and ways of thinking about concussion that currently impede research design and block advancements in care of TBI. Results are presented in the form of a multi-scale conceptual framework intended to synthesize knowledge across disciplines, improve research design, and provide a broader, multi-scale model for understanding concussion pathophysiology, classification, and treatment

Inertial sensors reveal subtle motor deficits when walking with horizontal head turns after concussion

Objective: To examine whether horizontal head turns while seated or while walking, when instrumented with inertial sensors, were sensitive to the acute effects of concussion and whether horizontal head turns had utility for concussion management. Setting: Applied field setting, athletic training room. Participants: Twenty-four collegiate athletes with sports-related concussion and 25 healthy control athletes. Design: Case-control; longitudinal. Main Measures: Peak head angular velocity and peak head angle (range of motion) when performing head turns toward an auditory cue while seated or walking. Gait speed when walking with and without head turns. Results: Athletes with acute sports-related concussion turned their head slower than healthy control subjects initially (group β = −49.47; SE = 16.33; P = .003) and gradually recovered to healthy control levels within 10 days postconcussion (group × time β = 4.80; SE = 1.41; P < .001). Peak head velocity had fair diagnostic accuracy in differentiating subjects with acute concussion compared with controls (areas under the receiver operating characteristic curve [AUC] = 0.71-0.73). Peak head angle (P = .17) and gait speed (P = .64) were not different between groups and showed poor diagnostic utility (AUC = 0.57-0.62). Conclusion: Inertial sensors can improve traditional clinical assessments by quantifying subtle, nonobservable deficits in people following sports-related concussion

The Dynamics of Concussion: Mapping Pathophysiology, Persistence, and Recovery with Causal-loop Diagramming

Concussion, also known as mild traumatic brain injury (mTBI),1 is a significant public health issue responsible for a variety of cognitive, emotional, and somatic symptoms and deficits (3). It is unclear why some individuals appear to recover relatively quickly while others suffer prolonged symptoms and impairments (4–7). Robust clinical means of diagnosis, prognosis, and treatment are also lacking (8–11). Research is hindered by an inadequate classification system for traumatic brain injury (TBI) (12), “poor” study quality (13, 14), disagreement about appropriate inclusion and exclusion criteria for concussion (8, 15), and an incomplete understanding of underlying pathophysiology (16–18). The heterogeneity and complexity seen in concussion further complicate research, particularly efforts to individualize treatment (19–22)

Analysis of free-living mobility in people with mild traumatic brain injury and healthy controls: quality over quantity

Balance and mobility issues are common non-resolving symptoms following mild traumatic brain injury (mTBI). Current approaches for evaluating balance and mobility following an mTBI can be subjective and suboptimal as they may not be sensitive to subtle deficits, particularly in those with chronic mTBI. Wearable inertial measurement units (IMU) allow objective quantification of continuous mobility outcomes in natural free-living environments. This study aimed to explore free-living mobility (physical activity and turning) of healthy and chronic mild traumatic brain injury (mTBI) participants using a single IMU. Free-living mobility was examined in 23 healthy control (48.56 ± 23.07 years) and 29 symptomatic mTBI (40.2 ± 12.1 years) participants (average 419 days post-injury, persistent balance complaints) over 1 week, using a single IMU placed at the waist. Free-living mobility was characterized in terms of macro (physical activity volume, pattern and variability) and micro-level (discrete measures of turning) features. Macro-level outcomes showed those with chronic mTBI had similar quantities of mobility compared with controls. Micro-level outcomes within walking bouts showed that chronic mTBI participants had impaired quality of mobility. Specifically, people with chronic mTBI made larger turns, had longer turning durations, slower average and peak velocities (all p < 0.001), and greater turn variability compared with controls. Results highlighted that the quality rather than quantity of mobility differentiated chronic mTBI from controls. Our findings support the use of free-living IMU continuous monitoring to enhance understanding of specific chronic mTBI-related mobility deficits. Future work is required to develop an optimal battery of free-living measures across the mTBI spectrum to aid application within clinical practice

The effectiveness of a web-based resource in improving postconcussion management in high schools

BACKGROUND: Because many sports concussions happen during school-sponsored sports events, most state concussion laws specifically hold schools accountable for coach training and effective concussion management practices. Brain 101: The Concussion Playbook is a web-based intervention that includes training in sports concussion for each member of the school community, presents guidelines on creating a concussion management team, and includes strategies for supporting students in the classroom. METHODS: The group randomized controlled trial examined the efficacy of Brain 101 in managing sports concussion. Participating high schools (N=25) were randomly assigned to the Brain 101 intervention or control. Fall athletes and their parents completed online training, and Brain 101 school administrators were directed to create concussion management policy and procedures. RESULTS: Student athletes and parents at Brain 101 schools significantly outperformed those at control schools on sports concussion knowledge, knowledge application, and behavioral intention to implement effective concussion management practices. Students who had concussions in Brain 101 schools received more varied academic accommodations than students in control schools. CONCLUSIONS: Brain 101 can help schools create a comprehensive school-wide concussion management program. It requires minimal expenditures and offers engaging and effective education for teachers, coaches, parents, and students

The Dynamics of Concussion: Mapping Pathophysiology, Persistence, and Recovery With Causal-Loop Diagramming

Despite increasing public awareness and a growing body of literature on the subject of concussion, or mild traumatic brain injury, an urgent need still exists for reliable diagnostic measures, clinical care guidelines, and effective treatments for the condition. Complexity and heterogeneity complicate research efforts and indicate the need for innovative approaches to synthesize current knowledge in order to improve clinical outcomes. Methods from the interdisciplinary field of systems science, including models of complex systems, have been increasingly applied to biomedical applications and show promise for generating insight for traumatic brain injury. The current study uses causal-loop diagramming to visualize relationships between factors influencing the pathophysiology and recovery trajectories of concussive injury, including persistence of symptoms and deficits. The primary output is a series of preliminary systems maps detailing feedback loops, intrinsic dynamics, exogenous drivers, and hubs across several scales, from micro-level cellular processes to social influences. Key system features, such as the role of specific restorative feedback processes and cross-scale connections, are examined and discussed in the context of recovery trajectories. This systems approach integrates research findings across disciplines and allows components to be considered in relation to larger system influences, which enables the identification of research gaps, supports classification efforts, and provides a framework for interdisciplinary collaboration and communication—all strides that would benefit diagnosis, prognosis, and treatment in the clinic

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<p>Despite increasing public awareness and a growing body of literature on the subject of concussion, or mild traumatic brain injury, an urgent need still exists for reliable diagnostic measures, clinical care guidelines, and effective treatments for the condition. Complexity and heterogeneity complicate research efforts and indicate the need for innovative approaches to synthesize current knowledge in order to improve clinical outcomes. Methods from the interdisciplinary field of systems science, including models of complex systems, have been increasingly applied to biomedical applications and show promise for generating insight for traumatic brain injury. The current study uses causal-loop diagramming to visualize relationships between factors influencing the pathophysiology and recovery trajectories of concussive injury, including persistence of symptoms and deficits. The primary output is a series of preliminary systems maps detailing feedback loops, intrinsic dynamics, exogenous drivers, and hubs across several scales, from micro-level cellular processes to social influences. Key system features, such as the role of specific restorative feedback processes and cross-scale connections, are examined and discussed in the context of recovery trajectories. This systems approach integrates research findings across disciplines and allows components to be considered in relation to larger system influences, which enables the identification of research gaps, supports classification efforts, and provides a framework for interdisciplinary collaboration and communication—all strides that would benefit diagnosis, prognosis, and treatment in the clinic.</p