HEART RATE VARIABILITY AND EXERTIONAL TASK ANALYSIS IN THE RECOVERY OF MILD TRAUMATIC BRAIN INJURY IN SERVICEMEMBERS (HEARTS)

ABSTRACT Julianna H. Prim: Heart Rate Variability and Exertional Task Analysis in the Recovery of Mild Traumatic Brain Injury in Servicemembers (HEARTS) (under the direction of Karen McCulloch) Context: The Defense and Veterans Brain Injury Center (DVBIC) guideline for Healthcare Providers treating mild traumatic brain injury (mTBI) recommends an exertional test before return to duty (RTD), yet no standardized test currently exists. Autonomic nervous system (ANS) impairments after concussion may be measured by heart rate variability (HRV). Objective: To develop clinically feasible exertional tasks to assess ANS balance with HRV measurements that can identify deficits and aid clinicians in RTD decisions for service members (SMs) with acute mTBI. Methods: 44 participants (40 Heathy Controls-HC, 4 mTBI) completed our exertional testing protocol while wearing heart rate (HR) monitors. After baseline rest, participants completed two short exertional tasks: a stepping and push-up task with a recovery period after each. The stepping task was 6 minutes with speed increases every 2 minutes utilizing a metronome for pacing and a 12’ step. The push-up task was a maximum of two minutes, self-paced, with total number recorded. Main Outcomes: (1) HR and HRV measures for two sensors, observational measures of time, space, equipment, physiological response in HC; (2) mTBI and HC HRV measures during resting, exertion, and recovery. Case series of task performance for mTBI participants, (3) successful task completion, exertion level, symptoms, HR. Results: (1) High reliability between the PolarH10 monitor and Faros180 ECG in HR and HRV component analyses during resting and exertional conditions was found. Both tasks met standards of clinical feasibility and physiological response. (2) mTBI SMs had lower baseline and recovery values of cardiac vagal control compared to HC. mTBI SMs also had lower rate of cardiac vagal recovery and heart period recovery compared to HC. Both tasks provoked symptoms in a majority of mTBI SMs, even with reported readiness to RTD. (3) Both tasks had similar completion, symptom and exertion levels. Conclusions: Completion of exertional tasks provided insight on recovery. An objective physiological measure could be used alongside symptom report and clinical opinion in prescribing activity and managing recovery after acute mTBI. Future research should prioritize clinical implementation of exertional tasks and how the physiological measure of HRV can be used clinically.Doctor of Philosoph

Clinical Utility and Analysis of the Run-Roll-Aim Task: Informing Return-to-Duty Readiness Decisions in Active-Duty Service Members

Introduction The Assessment of Military Multitasking Performance (AMMP1) consists of six dual-task and multitask military-relevant performance-based assessments which were developed to provide assistance in making return-to-duty decisions after concussion or mild traumatic brain injury (mTBI.) The Run-Roll-Aim (RRA) task, one component of the AMMP, was developed to target vulnerabilities following mTBI including attention, visual function, dynamic stability, rapid transition, and vestibular function. One aim of this study was to assess the known-group and construct validity of the RRA, and additionally to further explore reliability limitations reported previously. Materials and Methods A cross-sectional study consisting of 84 Active Duty service members in two groups (healthy control – HC and individuals experiencing persistent mTBI symptoms) completed neurocognitive tests and the RRA. The RRA task requires a high level of mobility and resembles military training activities in a maneuver that includes combat rolls, fast transitions, obstacle avoidance, and visual search. Observational and inertial sensor data were compared between groups and performance across four trial times was compared within groups. Correlations between RRA results and neurocognitive test scores were analyzed. Results Simple observational measures (time, errors) did not differ between groups. Spectral power analysis of the inertial sensor data showed significant differences in motor performance between groups. Within group one-way ANOVAs showed that in HC trial 1, time was significantly different than trials 2,3 and 4 (F(3,47) = 4.60, p < 0.01, Tukey HSD p < 0.05) while the mTBI group showed no significant difference in time between trials. During testing individuals with mTBI were less likely to complete the multiple test trials or required additional rest between trials than HCs (χ2 = 10.78, p < 0.01). Small but significant correlations were seen with two neurocognitive tests of attention and RRA performance time. Conclusion While observational scores were not sensitive to group differences, inertial sensor data showed motor performance on the forward run, combat roll, and backward run differed significantly between groups. The RRA task appeared challenging and provoked symptoms in the mTBI group, causing 8 of 33 mTBI participants to stop the task or require additional rest between trials while none of the HC participants had to stop. Individuals with mTBI demonstrated slower learning of the complex motor sequence compared to HCs who had significant improvement after one trial of RRA. Complex novel training maneuvers like RRA may aid clinicians in informing return to duty decisions

Efficacy of Virtual Care for Depressive Disorders: Systematic Review and Meta-analysis

BackgroundThe COVID-19 pandemic has created an epidemic of distress-related mental disorders such as depression, while simultaneously necessitating a shift to virtual domains of mental health care; yet, the evidence to support the use of virtual interventions is unclear. ObjectiveThe purpose of this study was to evaluate the efficacy of virtual interventions for depressive disorders by addressing three key questions: (1) Does virtual intervention provide better outcomes than no treatment or other control conditions (ie, waitlist, treatment as usual [TAU], or attention control)? (2) Does in-person intervention provide better outcomes than virtual intervention? (3) Does one type of virtual intervention provide better outcomes than another? MethodsWe searched the PubMed, EMBASE, and PsycINFO databases for trials published from January 1, 2010, to October 30, 2021. We included randomized controlled trials of adults with depressive disorders that tested a virtual intervention and used a validated depression measure. Primary outcomes were defined as remission (ie, no longer meeting the clinical cutoff for depression), response (ie, a clinically significant reduction in depressive symptoms), and depression severity at posttreatment. Two researchers independently selected studies and extracted data using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Risk of bias was evaluated based on Agency for Healthcare and Research Quality guidelines. We calculated odds ratios (ORs) for binary outcomes and standardized mean differences (SMDs) for continuous outcomes. ResultsWe identified 3797 references, 24 of which were eligible. Compared with waitlist, virtual intervention had higher odds of remission (OR 10.30, 95% CI 5.70-18.60; N=619 patients) and lower posttreatment symptom severity (SMD 0.81, 95% CI 0.52-1.10; N=1071). Compared with TAU and virtual attention control conditions, virtual intervention had higher odds of remission (OR 2.27, 95% CI 1.10-3.35; N=512) and lower posttreatment symptom severity (SMD 0.25, 95% CI 0.09-0.42; N=573). In-person intervention outcomes were not significantly different from virtual intervention outcomes (eg, remission OR 0.84, CI 0.51-1.37; N=789). No eligible studies directly compared one active virtual intervention to another. ConclusionsVirtual interventions were efficacious compared with control conditions, including waitlist control, TAU, and attention control. Although the number of studies was relatively small, the strength of evidence was moderate that in-person interventions did not yield significantly better outcomes than virtual interventions for depressive disorders