NeuroRehabilitation - Volume 55, issue 3

Authors: Cifu, David X. | Hinds II, Sidney R.

Article Type: Editorial

DOI: 10.3233/NRE-246007

Citation: NeuroRehabilitation, vol. 55, no. 3, pp. 243-244, 2024

Authors: Landvater, Jeremy | Kim, Sharon | Caswell, Keenan | Kwon, Caroline | Odafe, Emamoke | Roe, Grace | Tripathi, Ananya | Vukovics, Christian | Wang, Jonathan | Ryan, Keith | Cocozza, Victoria | Brock, Matthew | Tchopev, Zahari | Tonkin, Brionn | Capaldi, Vincent | Collen, Jacob | Creamer, Jennifer | Irfan, Muna | Wickwire, Emerson M. | Williams, Scott | Werner Jr., J. Kent

Article Type: Review Article

Abstract: BACKGROUND: Traumatic brain injury (TBI) is a hallmark of wartime injury and is related to numerous sleep wake disorders (SWD), which persist long term in veterans. Current knowledge gaps in pathophysiology have hindered advances in diagnosis and treatment. OBJECTIVE: We reviewed TBI SWD pathophysiology, comorbidities, diagnosis and treatment that have emerged over the past two decades. METHODS: We conducted a literature review of English language publications evaluating sleep disorders (obstructive sleep apnea, insomnia, hypersomnia, parasomnias, restless legs syndrome and periodic limb movement disorder) and TBI published since 2000. We excluded studies that were not specifically evaluating …TBI populations. RESULTS: Highlighted areas of interest and knowledge gaps were identified in TBI pathophysiology and mechanisms of sleep disruption, a comparison of TBI SWD and post-traumatic stress disorder SWD. The role of TBI and glymphatic biomarkers and management strategies for TBI SWD will also be discussed. CONCLUSION: Our understanding of the pathophysiologic underpinnings of TBI and sleep health, particularly at the basic science level, is limited. Developing an understanding of biomarkers, neuroimaging, and mixed-methods research in comorbid TBI SWD holds the greatest promise to advance our ability to diagnose and monitor response to therapy in this vulnerable population. Show more

Keywords: Traumatic brain injury, sleep, military, veteran, post traumatic stress disorder, sleep wake disorder, neuroinflammation

DOI: 10.3233/NRE-230380

Citation: NeuroRehabilitation, vol. 55, no. 3, pp. 245-270, 2024

Authors: Barnett, Nathan | Ljubic, Milica | Chung, Joyce | Capizzi, Allison

Article Type: Research Article

Abstract: BACKGROUND: U.S. Special Operations Forces (SOF) are at increased risk of multiple mild traumatic brain injury (mmTBI). Testosterone was prescribed for several participants in a VA program designed to address sequelae of mmTBI for SOF. OBJECTIVE: To determine testosterone prevalence in the Palo Alto VA Intensive Evaluation and Treatment Program (IETP) and observe for association between testosterone and neurobehavioral outcomes. METHODS: A retrospective cohort study included patients in the Palo Alto VA IETP. Sociodemographic data, testosterone blood levels, and neurobehavioral outcomes were collected from medical records. RESULTS: 55 IETP participants were included: six were …testosterone users; the rest were classified as non-users. Testosterone use in this population is 11%, higher than reported national averages in the U.S. Of the 6 testosterone users, 2 (33%) had a formal diagnosis of hypogonadism prior to initiation of testosterone. Neurobehavioral outcome scores between testosterone users and non-users failed to show statistically significant differences, except for the PROMIS pain score, which was higher in the testosterone user population. CONCLUSION: The current study did not find an association between mmTBI, testosterone use, or testosterone level and neurobehavioral outcomes. This study highlights a need to further examine the relationship between hypogonadism, mmTBI, SOF culture around testosterone, and the effects of testosterone use in this population. Show more

Keywords: Traumatic brain injury, TBI, neuroendocrine dysfunction, hypogonadism, multiple mild traumatic brain injury, testosterone, special operations forces

DOI: 10.3233/NRE-230291

Citation: NeuroRehabilitation, vol. 55, no. 3, pp. 271-279, 2024

Authors: Monti, Katrina | Conkright, MAJ William | Eagle, Shawn R. | Lawrence, David W. | Dretsch, LTC Michael

Article Type: Review Article

Abstract: BACKGROUND: Veterans Affairs and the Department of Defense (DOD) acknowledge that nutrition may be a modifier of mild traumatic brain injury (TBI) sequelae. Military clinicians are considering nutritional supplements and dietary interventions when managing patients with mild TBI. Therefore, clinicians should be familiar with the current evidence for nutritional interventions in mild TBI and special considerations related to the military lifestyle. OBJECTIVE: This narrative review aims to summarize the existing evidence surrounding the role of special diets and select nutrients in mild TBI outcomes, gut microbiota changes, and special considerations for Service members and Veterans recovering from mild …TBI. METHODS: We conducted a literature review in PubMed and Google Scholar limited to nutritional interventions and nine topics with primary focus on mild TBI, although we included some articles related to moderate-to-severe TBI where relevant: 1) ketogenic diet, 2) Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND) diet, 3) omega-3 fatty acids, 4) creatine, 5) vitamin D, 6) weight management, 7) gut microbiota, 8) caffeine, and 9) alcohol. We summarized key findings and safety factors where appropriate for each intervention. We also identified nutritional supplement safety and operational rations considerations and areas in need of further research. RESULTS: Preclinical studies and early human trials suggest that the specific nutrients and diets discussed in the current article may offer neuroprotection or benefit during mild TBI rehabilitation. Omega-3 fatty acids, creatine, and vitamin D are generally safe when taken within recommended guidelines. CONCLUSION: More evidence is needed to support nutritional recommendations for enhancing neuroprotection and mitigating mild TBI symptoms in humans. The DOD’s Warfighter Nutrition Guide recommends a whole food diet rich in antioxidants, phytonutrients, omega-3 fatty acids, micronutrients, probiotics, and fiber to optimize long-term health and performance. Show more

Keywords: Traumatic brain injury, concussion, nutrition, diet, rehabilitation, gut microbiome, military

DOI: 10.3233/NRE-230241

Citation: NeuroRehabilitation, vol. 55, no. 3, pp. 281-294, 2024

Authors: Babakhanyan, Ida | Sedigh, Randi | Remigio-Baker, Rosemay | Hungerford, Lars | Bailie, Jason M.

Article Type: Research Article

Abstract: BACKGROUND: While there is extensive empirical support and clinical guidance for the treatment of mild traumatic brain injury (mTBI) and post-traumatic stress disorder (PTSD) individually, less is known about treating the comorbid presentation of both conditions. OBJECTIVE: The purpose of this review article is to provide information on the mental health treatment needs of service members (SMs) engaged in traumatic brain injury (TBI) rehabilitation. It also aims to offer a framework for an integrated treatment approach to address the cognitive and psychological health needs of warfighters. METHODS: We review the prevalence and outcomes associated with comorbid …TBI and PTSD and present relevant access to care considerations. Additionally, we identify an integrated approach to TBI treatment which takes psychological trauma into consideration. We introduce a trauma-informed care (TIC) model with specified diagnostic and treatment considerations for the service member and veteran (SM/V) communities. TIC is a strengths-based framework that raises the system-wide awareness of treatment facilities to the impact of psychological trauma on behavioral health. RESULTS: A comprehensive diagnostic approach is recommended with considerations for symptom etiology. Clinical considerations derived from available guidelines are identified to meet critical treatment needs for SM/Vs presenting for TBI treatment with a remote history of mTBI and psychological trauma or known PTSD. Clinical practice guidelines are used to inform an integrated TBI treatment model and maximize rehabilitation efforts for warfighters. CONCLUSION: Given the prevalence of comorbid TBI and PTSD among SM/Vs and its impact on outcomes, this review presents the integration of appropriate diagnostics and treatment practices, including the incorporation of clinical practice guidelines (CPGs) into TBI rehabilitation. Show more

Keywords: Traumatic brain injury, post-traumatic stress disorder, rehabilitation, military, post-concussive symptoms, treatment model, concussion, head trauma, post-concussion syndrome, trauma

DOI: 10.3233/NRE-230274

Citation: NeuroRehabilitation, vol. 55, no. 3, pp. 295-302, 2024

Authors: McGeary, Donald | Swan, Alicia A. | Kennedy, Eamonn | Dismuke-Greer, Clara E. | McGeary, Cindy | Sico, Jason J. | Amuan, Megan E. | Manhapra, Ajay | Bouldin, Erin D. | Watson, Paul | Kenney, Kimbra | Myers, Maddy | Werner Jr. , J. Kent | Mitchell, James L. | Carlson, Kathleen | Delgado, Roxana | Esmaeili, Aryan | Pugh, Mary Jo

Article Type: Research Article

Abstract: BACKGROUND: Chronic headache after traumatic brain injury (TBI) is a common, yet disabling, disorder whose diverse clinical characteristics and treatment needs remain poorly defined. OBJECTIVE: To examine diagnostic coding patterns and cost among military Veterans with comorbid chronic headache and TBI. METHODS: We identified 141,125 post-9/11 era Veterans who served between 2001 and 2019 with a headache disorder diagnosed after TBI. We first identified patterns of Complex Headache Combinations (CHC) and then compared the patterns of healthcare costs in 2022-dollar values in the three years following the TBI diagnosis. RESULTS: Veterans had diverse individual …headache and CHC diagnoses with uniformly high cost of care. Post-whiplash and post-TBI CHCs were common and consistently associated with higher costs after TBI than those with other types of headache and CHCs. Post-TBI migraine had the highest unadjusted mean inpatient ($27,698), outpatient ($61,417), and pharmacy ($4,231) costs, which persisted even after adjustment for confounders including demographic, military, and clinical characteristics. CONCLUSION: Headache diagnoses after TBI, particularly those diagnosed with post-traumatic headache, are complex, and associated with dual high cost and care burdens. More research is needed to examine whether this higher expenditure reflects more intensive treatment and better outcomes or refractory headache with worse outcomes. Show more

Keywords: Post-traumatic headache (PTH), health care costs, Veterans, traumatic brain injuries (TBI), mild TBI (mTBI), rehabilitation

DOI: 10.3233/NRE-230277

Citation: NeuroRehabilitation, vol. 55, no. 3, pp. 303-317, 2024

Authors: Ho, Dan P. | Andersen, Michael | Hammer, Daniel

Article Type: Research Article

Abstract: BACKGROUND: Mandibular reconstruction has historically been challenging due to the complex, highly functional, and esthetic nature of the anatomy. The most common etiologies of these defects requiring resection include trauma, benign tumors, and malignant pathology. Mandibular defects have been treated with little consideration for neural reconstruction, leaving patient’s orally incompetent with associated social stigma. Although recent advances in reconstructive techniques improve oral rehabilitation, immediate inferior alveolar nerve (IAN) reconstruction has not been widely adapted. OBJECTIVE: Here-in we seek to discuss the innovations of neural reconstruction of large segment mandibular defects and associated IAN defects and present an example …case performed at Naval Medical Center San Diego (NMCSD). METHODS: Pertinent literature discussing maxillofacial reconstruction and nerve repair using autogenous nerve harvest and allograft was queried from available online resources. RESULTS: Six patients have received immediate reconstruction of the IAN using processed nerve allograft over the past three years. All obtained sensation to S3 within six months of surgery. CONCLUSION: IAN repair using nerve allografts in conjunction with free flap reconstruction for large mandibular defects is a viable treatment and should be the new paradigm in maxillofacial reconstruction as it provides substantial quantifiable and qualitative improvements in social, functional, and esthetic outcomes of care. Show more

Keywords: Fibula free flap, inferior alveolar nerve, jaw-in-a-day, maxillofacial reconstruction, nerve allograft

DOI: 10.3233/NRE-230253

Citation: NeuroRehabilitation, vol. 55, no. 3, pp. 319-327, 2024

Authors: Miller, Austin R. | Martindale, Sarah L. | Rowland, Jared A. | Walton, Samuel | Talmy, Tomer | Walker, William C.

Article Type: Review Article

Abstract: BACKGROUND: A significant factor for the high prevalence of traumatic brain injury (TBI) among U.S. service members is their exposure to explosive munitions leading to blast-related TBI. Our understanding of the specific clinical effects of mild TBI having a component of blast mechanism remains limited compared to pure blunt mechanisms. OBJECTIVE: The purpose of this review is to provide a synopsis of clinical research findings on the long-term effects of blast-related mild TBI derived to date from the Long-Term Impact of Military-Relevant Brain Injury Consortium - Chronic Effects of Neurotrauma Consortium (LIMBIC-CENC). METHODS: Publications on blast-related …mild TBI from LIMBIC-CENC and the LIMBIC-CENC prospective longitudinal study (PLS) cohort were reviewed and their findings summarized. Findings from the broader literature on blast-related mild TBI that evaluate similar outcomes are additionally reviewed for a perspective on the state of the literature. RESULTS: The most consistent and compelling evidence for long-term effects of blast-related TBI is for poorer psychological health, greater healthcare utilization and disability levels, neuroimaging impacts on brain structure and function, and greater headache impact on daily life. To date, evidence for chronic cognitive performance deficits from blast-related mild TBI is limited, but futher research including crucial longitudinal data is needed. CONCLUSION: Commentary is provided on: how LIMBIC-CENC findings assimilate with the broader literature; ongoing research gaps alongside future research needs and priorities; how the scientific community can utilize the LIMBIC-CENC database for independent or collaborative research; and how the evidence from the clinical research should be assimilated into clinical practice. Show more

Keywords: Traumatic brain injury, mild traumatic brain injury, concussion, blast injuries, military medicine, veterans health, outcome studies

DOI: 10.3233/NRE-230268

Citation: NeuroRehabilitation, vol. 55, no. 3, pp. 329-345, 2024

Authors: Gano, Amanda | Gold, Joanne | Remigio-Baker, Rosemay A. | Monti, Katrina

Article Type: Research Article

Abstract: BACKGROUND: Concussion, also known as mild traumatic brain injury (mTBI), is a condition with unique ties to military service. Service members (SMs) are inherently at a higher risk for concussive injuries due to the intense physical training environment and combat operational tempo required to serve. The Traumatic Brain Injury Center of Excellence (TBICoE) is the US Department of Defense authority on this condition and provides a thorough approach to management of concussion and associated symptom sequela. OBJECTIVES: This article seeks to review the TBICoE approach to the management and rehabilitation of military SMs with mTBI, and highlight resources …available to military medical providers. METHODS: The authors reviewed evidence and TBICoE resources to provide this comprehensive overview of the TBICoE approach to management and rehabilitation of concussion in military SMs. RESULTS: A progressive return to activity protocol in conjunction with symptom-guided management of common post-concussive sequelae, including headache, vestibular and oculomotor issues, sleep dysfunction, cognitive rehabilitation, and behavioral health comorbidities are essential for concussion management in the acute, post-acute and chronic phases of injury. CONCLUSION: The TBICoE approach to the rehabilitation of military SMs is comprehensive, and includes initial management with a stepwise return to duty protocol and an objective return to duty screening. The mainstays of treatment for SMs with post-acute and chronic post-concussion symptoms are headache management, vestibular and oculomotor rehabilitation, sleep interventions, cognitive rehabilitation, and early intervention for behavioral health comorbidities. These evidence-based strategies may be applied in the treatment of SMs in the US and internationally. Show more

Keywords: Traumatic brain injury, concussion, military, rehabilitation, service members, veterans

DOI: 10.3233/NRE-230269

Citation: NeuroRehabilitation, vol. 55, no. 3, pp. 347-356, 2024

Authors: Dunn, Walter | Bershad, Anya | Krantz, David E | Vermetten, Eric

Article Type: Review Article

Abstract: BACKGROUND: Neurorehabilitation in military populations is complicated by higher rates of PTSD and unique characteristics of military institutions. These factors can adversely impact the patient-therapist therapeutic alliance and engagement with the rehabilitation process leading to poorer outcomes. MDMA is a non-classical psychedelic with pro-social and fear regulating properties. MDMA-assisted therapy is being explored as a novel treatment for PTSD that potentially offers rapid symptom improvement and enhances therapeutic alliance. OBJECTIVE: A review of MDMA-assisted therapy for PTSD is provided in the context of neurorehabilitation in military populations. The molecular mechanism of MDMA is outlined and a novel application …of MDMA for neurorehabilitation is proposed. METHODS: This is an expert review and synthesis of the literature. RESULTS: Results from late-stage clinical trials suggest MDMA-assisted therapy for PTSD would be of particular benefit for military populations with PTSD. The unique pro-social properties of MDMA could be leveraged to enhance the therapeutic alliance and patient engagement during neurorehabilitation. CONCLUSION: The unique qualities and benefits of MDMA and MDMA-assisted therapy for PTSD suggest relevant application in military personnel undergoing neurorehabilitation. There are many similarities in patient-therapist dynamics in PTSD treatment and neurorehabilitation. The properties of MDMA which enhance therapeutic alliance, downregulate fear, and increase cognitive flexibility would potentially benefit both military personnel with and without PTSD undergoing neurorehabilitation. Show more

Keywords: MDMA, PTSD, neurorehabilitation, rehabilitation, military personnel, psychedelics

DOI: 10.3233/NRE-230270

Citation: NeuroRehabilitation, vol. 55, no. 3, pp. 357-368, 2024

Authors: Hinds II, Sidney R. | Cifu, David X.

Article Type: Research Article

Abstract: BACKGROUND: Conducting mild traumatic brain injury (mTBI) longitudinal studies across multiple sites is a challenging endeavor which has been made more challenging because of COVID-19. OBJECTIVE: This article briefly describes several concerns that need to be addressed during the conduct of research to account for COVID-19’s impact. METHODS: The recent actions and steps taken by the Long-term Impact of Military-relevant Brain Injury Consortium (LIMBIC)-Chronic Effects of Neurotrauma Consortium (CENC) researchers are reviewed. RESULTS: COVID-19’s effects on the conduct of LIMBIC-CENC for the short-term and long-term were considered to ensure the study continued safely for …participants and researchers. COVID-19 may have long-lasting health and especially neurological effects which may confound the quantitative and qualitative measures of this any comparable longitudinal studies. CONCLUSION: The recognition, understanding, and preparation of COVID-19’s impact on a longitudinal military and veteran mTBI population is crucial to successfully conducting LIMBIC-CENC and similar neurological research studies. Developing a plan based on the best available information while remaining agile as new information about COVID-19 emerge, is essential. Research presented in this special issue underscores the complexity of studying long-term effects of mTBI, in a population exposed to and symptomatic from COVID-19. Show more

Keywords: Traumatic brain injury, COVID-19, military, veteran, neurotrauma, neurorehabilitation, neurodegeneration

DOI: 10.3233/NRE-230272

Citation: NeuroRehabilitation, vol. 55, no. 3, pp. 369-374, 2024

Authors: Ragsdale, Katie A. | Nichols, Anastacia A. | Mehta, Mansi | Maples-Keller, Jessica L. | Yasinski, Carly W. | Hyatt, Courtland S. | Watkins, Laura E. | Loucks, Laura A. | Carbone, Elizabeth | Rauch, Sheila A. M. | Rothbaum, Barbara O.

Article Type: Research Article

Abstract: BACKGROUND: The Emory Healthcare Veterans Program (EHVP) is a multidisciplinary intensive outpatient treatment program for post-9/11 veterans and service members with invisible wounds, including posttraumatic stress disorder (PTSD), traumatic brain injury (TBI), substance use disorders (SUD), and other anxiety- and depression-related disorders. OBJECTIVE: This article reviews the EHVP. METHODS: The different treatment tracks that provide integrated and comprehensive treatment are highlighted along with a review of the standard, adjunctive, and auxiliary services that complement individualized treatment plans. RESULTS: This review particularly emphasizes the adjunctive neurorehabilitation service offered to veterans and service members with a …TBI history and the EVHP data that indicate large reductions in PTSD and depression symptoms across treatment tracks that are maintained across 12 months follow up. Finally, there is a discussion of possible suboptimal treatment response and the pilot programs related to different treatment augmentation strategies being deploying to ensure optimal treatment response for all. CONCLUSION: Published data indicate that the two-week intensive outpatient program is an effective treatment program for a variety of complex presentations of PTSD, TBI, SUD, and other anxiety- and depression-related disorders in veterans and active duty service members. Show more

Keywords: Posttraumatic stress disorder, traumatic brain injury, military psychiatry, veterans, mental health, therapy

DOI: 10.3233/NRE-230235

Citation: NeuroRehabilitation, vol. 55, no. 3, pp. 375-384, 2024

Authors: Springer, Shauna | Whitmer, Paul | Steinlin, Morgan | Gray, Lindsey | Blankfield, Jason

Article Type: Review Article

Abstract: BACKGROUND: For decades, thousands of active-duty service members have sought treatment for trauma exposure. Stellate ganglion block (SGB) is a fast-acting nerve block documented in medical literature for nearly a century that has shown promise as a potentially life-altering treatment for post-traumatic stress (PTS). OBJECTIVE: This review aims to answer the practical questions of those who support individuals suffering from trauma: (1) SGB’s safety profile (2) efficacy data (3) potential advantages and limitations, (4) a cross-cultural application example, (5) and the use of SGB in combination with talk therapy to optimize clinical outcomes. METHODS: The current …body of literature, to include several large case series, meta-analyses, and a sufficiently powered randomized controlled trial, were reviewed, and presented to describe the history of SGB for emotional trauma symptoms and address the objectives of this review. RESULTS: Critical consideration is given to the safety and efficacy data on SGB and the evolution in safety-related technologies. Advantages such as decreased barriers to care, rapid onset, and decreased dropout and limitations such as treatment non-response, potential adverse effects, and misconceptions about the treatment are then described. Finally, the cross-cultural application of SGB is explored based on the deployment of SGB in Israel. CONCLUSION: SGB is associated with level 1B evidence and a reassuring safety profile. Evolving the model of care through the combined use of effective biological treatments like SGB with trauma informed talk therapy offers a hopeful path forward for supporting those who suffer from post-traumatic stress. Show more

Keywords: Stellate ganglion block, SGB, post-traumatic stress disorder, PTSD, combat stress disorder, nerve block, military health, veterans health

DOI: 10.3233/NRE-230236

Citation: NeuroRehabilitation, vol. 55, no. 3, pp. 385-396, 2024