Research Blog

Summarized by Daniel McBride, MD

A new research article has given us a fresh look at “cognitive motor dissociation.” This is a medical condition where people with serious brain injury appear to be asleep, but special tests show us they may still know what is happening around them. In fact, this new study shows that it may be even more common than we think. To better understand cognitive motor dissociation, first we will review brain injury and how to test brain activity. After a serious brain injury, the injured person may not wake up. Their heart is still beating and they are still breathing, but they appear to be in a deep sleep. This may be called a coma or a vegetative state. These people do not respond when asked questions or when their names are called. For a long time, doctors have been uncertain if these people still know what is happening around them. Can they hear our voices? Do they understand when their families are speaking to them? New high-tech tests are providing clues to help answer these questions. Have you ever seen a movie or TV show with a character in the hospital next to a beeping machine that “flatlines”? That machine is a type of heart monitor. It measures electrical activity in the heart. Every beep indicates one heartbeat, and the “flatline” means the heart has stopped beating. We have similar machines that can monitor activity in the brain. Stickers placed onto the head record the brain’s electrical activity. This test is called an EEG (electroencephalogram). You may have also seen an X-ray, which doctors use to take pictures of bones. There is another type of picture we can take of the brain, called an MRI (magnetic resonance imaging). The MRI uses a powerful magnet and special computers to build a 3D picture of the brain. There is even a special type of MRI, called fMRI (functional MRI), which shows us a “real time” or “live action” picture of brain activity. Using these two tests, the EEG and the fMRI, scientists are able to look at the activity of the brain. This brain activity follows certain patterns at certain times. For example, the brain shows one pattern when you are awake, and another pattern when you are asleep. The brain can show different patterns when reading, watching TV, or playing sports. But that is not the only time we see these brain patterns. Because the brain helps plan our behavior, it can show these special patterns even when you just think about an activity. For example, if you imagine throwing a baseball, your brain can show the same pattern as if you were actually throwing a ball. These brain activity patterns are called “task-based paradigms.” What does this have to do with brain injury? Remember, some people with serious brain injuries appear to be permanently asleep—in a coma, or in a vegetative state. We want to know if these people are still aware of what is happening around them. They do not seem to answer our questions or respond to our voices. But what if we use the special tests, the EEG and the fMRI? With these tests, scientists asked these people with brain injuries to perform the “task-based paradigms”—for example, to imagine throwing

a ball, or to imagine squeezing their fist. And even though these people appeared asleep, the tests showed their brain activity patterns matching the requested behaviors! This is cognitive motor association. A person appears to be in a coma, or in a vegetative state, unable to respond to the outside world, but their brains are still showing activity that suggests they can hear us. And this new study shows us that cognitive motor dissociation may happen more often than we thought. Past research showed cognitive motor dissociation in 10% to 20% of these patients, but this new study showed it in about 25% of patients. However, this study has some limitations. These tests, the EEG and fMRI, require special equipment and specially trained technicians. It is probably not possible to perform these tests on every brain injury patient who is unresponsive in a coma or a vegetative state. Also, the tests are not perfect. The two tests do not always agree with one another, and the tests may miss some brain activity in certain patients.

Nevertheless, scientists and doctors hope that this new study will help encourage further research into new methods to detect cognitive motor dissociation. One strategy may be to make the EEG and fMRI tests simpler and easier to use. Another approach could be to develop completely new tests to look for cognitive motor dissociation. The goal is to make these tests more common and improve our knowledge about this medical condition. Titled “Cognitive Motor Dissociation in Disorders of Consciousness,” this study was published in August 2024 in the The New England Journal of Medicine. The first author is Y.G. Bodien. The study looked at 353 patients at 6 hospitals in the United States and in Europe.

https://pubmed.ncbi.nlm.nih.gov/39141852/

Summarized by Theresa Ebo, MA

March 2024

Traumatic brain injury (TBI) is a life-changing event that can produce anywhere from mild life functioning impairments to lasting disability. The natural course of recovery for individuals who have experienced a moderate to severe TBI (msTBI) differs from the acute to chronic phases of recovery. While the initial impairment and associated need for care may be profound, this presentation does not necessarily translate into an unfavorable long-term functional outcome. The Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study aimed to systematically monitor patients’ functional outcomes after a TBI. The patients were observed from two weeks post-injury to 12-months, during which they received inpatient or outpatient rehabilitation services. The goal of the study was to assess the frequency and extent of recovery, from two weeks to 12 months, for patients who suffered moderate to severe TBI. The study included 484 individuals who presented to a level-one trauma center within 24 hours of their injury. The cause of injury included being an occupant or pedestrian in a motor vehicle crash, motorcycle crash, fall, assault, or other reason.

The results provide a positive outlook on recovery for patients with moderate to severe TBI. While 94% of the severe TBI and 79% of the moderate TBI group reported moderate to severe disability and required assistance with the basic aspects of their everyday lives at 12 months post-injury (i.e., feeding, using the toilet, and grooming themselves), a significant portion of the participants with msTBI had major improvements in life functioning, with many regaining their independence between 2 weeks to 12 months after their injury. More specifically, half of the severe group and three-quarters of the moderate group were able to function independently at home for at least eight hours per day. By 12 months, 62 out of 79 participants who were in a vegetative state at two weeks post-injury regained consciousness and 14 regained their orientation.

The article’s findings suggest that patients with msTBI experienced significant functional improvement as early as two weeks post-injury. By the end of the study (i.e., 12 months), patients saw improvement, though variable across participants, including independence at home; ability to shop; and improved work capacity and social functioning. While many participants’ impairments persisted at 12-months post injury, this study revealed that a significant percentage of patients with grave impairment during the early stage of recovery achieved favorable outcomes months later. Thus, impairments in patients with msTBI at two weeks post injury does not necessarily translate to poor long-term recovery.

The study investigates long-term outcomes (i.e., 12 months post-injury) of patients with moderate to severe TBI. The authors acknowledged some limitations, including that the definition of a favorable outcome varies from person to person. Additionally, while the study’s measures are widely accepted in TBI outcome research, they do not reflect all aspects and variables of clinical recovery. Further, two-week outcome ratings may have been influenced by sedating medications administered to the participants at that time. Finally, the study was conducted in settings with established clinical systems of care (i.e., level 1 trauma centers), which may limit the generalizability of the results to patients who may receive care in other settings.

10.1001/jamaneurol.2021.2043

Summarized by Dr. Ally Ferber, MD

February 2024

The article talks about athletes who experience a concussion while playing sports. A concussion is a type of brain injury that can happen when the head is hit hard or moves very quickly. This impact can lead to changes in how the brain works, affecting the cells (neurons) and causing different symptoms.

The article focuses on symptoms related to the vestibular-ocular-motor (VOM) system and how they impact an athlete’s return to sports and school performance. The VOM system involves balance, vision, and movement. If this system is disrupted, it can cause issues like dizziness, nausea, blurred vision, and difficulty reading.

Testing for problems in the VOM system isn’t common yet, but the article suggests it could be helpful. Using a screening tool to identify athletes with balance, vision, and movement issues, they found that those with symptoms in this system took longer to recover, had more severe symptoms, missed more school, and needed more time overall to get better.

In summary, using the VOM screening tool in the first two weeks after a sports-related concussion might help doctors identify athletes with specific issues. This can give athletes and their families an idea of how long the recovery might take, when they can return to sports, and when they can go back to school. It also allows doctors to recommend specific exercises to help athletes heal better.

https://pubmed.ncbi.nlm.nih.gov/33896286/

Summarized by Teja Makkapati, MD

January 2024

When someone ends up in the hospital, there is a high chance they might not be getting the right amount of nutrition, especially if they have experienced a traumatic brain injury (TBI). TBIs require extra nutrients for the brain to heal properly. Studies suggest that a large number of hospitalized patients, about 20-50%, end up malnourished, however there is not much research on how this specifically affects TBI patients.

For people with TBIs , their bodies go into overdrive trying to heal the brain. This means they need more calories and protein than usual. The study “Determination of calorie and protein intake among acute and sub-acute traumatic brain injury patients” looked at the dietary habits of 50 TBI patients to see how well they were eating during their hospital stay. They looked at their daily food intake, considering things like body mass index (BMI), age, and gender in their calculations.

The results showed that the more severe the TBI, the less people ate. Even though eating improved a bit over time, it still was no’t enough to meet their calorie needs. The most common reasons for this are pain, discomfort, and emotional issues after the injury which makes individuals want to eat less.

In summary, people with TBIs are not getting the nutrition they need, and those with more severe injuries are at a higher risk of developing malnutrition. This is a population at high risk of being malnourished and more studies are needed to find ways to help these patients get the right nutrition during their hospital stay for a quicker recovery.

https://pubmed.ncbi.nlm.nih.gov/32423779/

Summarized by Dr. Hannah Park

December 2023

Poor sleep is very common after a traumatic brain injury (TBI), and it affects more than 50% of patients. These sleep disturbances can include less total time sleeping, waking up from sleep more frequently, having poor quality sleep, and not feeling well-rested after sleep. Insomnia, or difficulty falling asleep, is the most common sleep disorder seen after a TBI and affects 50-70% of patients.

The reason why sleep disturbances develop after a TBI is not fully understood, but several theories include changes in hormones that affect our sleep/wake cycle, including melatonin and orexin/hypocretin. Also, TBI patients can develop mood disorders like anxiety and depression that makes it more difficult to get good quality sleep. Melatonin is a hormone naturally produced in the brain by the pineal gland. It has been used to help treat patients with circadian rhythm disorders such as insomnia, and it has been shown to improve the quality of sleep, how long it takes to fall asleep, and reducing waking up during the night.

The Utility of Melatonin for the Treatment of Sleep Disturbance After Traumatic Brain Injury: A Scoping Review. This study from 2023 looked at other research articles studying melatonin use after TBI, and they chose 9 articles to evaluate with a total of 251 participants including adults and kids. These studies were from all around the world and included all severities of TBI, from mild to severe. For the medications, they used either melatonin, Circadin (an melatonin that is slowly released throughout the day), or Ramelton (a drug that activates melatonin receptors) at doses between 2 to 10mg, and they took these medications for 3 to 12 weeks.

8 out of the 9 studies reported positive outcomes after melatonin treatment. Overall, patients had improved sleep duration, sleep quality, and daytime alertness. Melatonin also improved some mental health symptoms (anxiety and depression), cognitive function, and memory. Patients who had worse sleep patterns before starting melatonin had better responses. There were no serious adverse events with treatment of melatonin in adults and children up to doses of 10mg.

Interestingly, the medications studied caused some TBI patients to take the same amount of time to fall asleep or even more time to fall asleep by up to 5 minutes. This is different from other studies in non-TBI patients, where the medications helped patients to fall asleep more quickly. More research needs to be done to further examine this effect of the melatonin medications.

In conclusion, sleep disturbances are commonly seen after TBI, especially mild TBI. They can last for several years after an injury and make recovery more difficult because the brain doesn’t get proper rest and time to heal. Feeling tired during the day can also make it more difficult to participate in the therapies that will help with recovery. Melatonin and its related medications can help to reduce the effects and symptoms of sleep disturbances and has been well-tolerated in adults and kids. We need to do more research comparing the efficacy of these medications with other interventions like cognitive behavioral therapy, improved sleep hygiene, and alternative medications. For now, if you have a loved one who is suffering from sleep disturbances after TBI, it is reasonable to try adding melatonin under the direction of your doctors.

https://pubmed.ncbi.nlm.nih.gov/36243124/

Summarized by Dr. Jessie Chan
November 2023

A recent article titled, “Rehabilitation of Social Communication Skills in Patients with Acquired Brain Injury with Intensive and Standard Group Interactive Structured Treatment: A Randomized Controlled Trial” was published in the Archives of Physical Medicine and Rehabilitation by authors Ingebresten et al. People with brain injuries often have trouble with social communication, which makes it hard for them to fit back into their community. This can lead to loneliness and difficulty with making friends or finding and keeping a job.

Past studies showed that a treatment done once a week for 3 months can help people with acquired brain injuries communicate better and feel happier in their day-to-day lives. The treatment includes group activities, help with setting personal goals, homework, and active feedback. It helps with parts of communication like understanding what other people are thinking and not saying inappropriate things. There is not a lot of information on how long or often treatments should be, so the authors did an earlier study to test how well the same treatment done every day for one month would help patients. It showed that this shortened and frequent treatment worked about as well as the original treatment.

This study compared two groups of people in Norway who had acquired traumatic or nontraumatic brain injuries. Group A got standard treatment which was once a week for 3 months in an outpatient clinic. Group B was first put on a waitlist without treatment for social communication for 9 months. This created a “no treatment” group to compare against. Group B then had intensive treatment which was every day for one month in an inpatient cognitive rehabilitation unit. This group of patients were encouraged to go home on weekends during treatment to practice their skills in real life with friends and family. The results showed that both the standard and intensive treatments helped people with brain injuries communicate better compared to no treatment. At the end of the study, Group A and Group B had equal improvements in social communication skills, even when they were retested 6 months later.

It seems that standard outpatient and intensive inpatient social communication treatment are both good options for people with acquired injuries to communicate better. One factor to think about is that intensive inpatient treatment can be harder to find, but it could be a good option for people who have fewer friends and family to practice social skills with or would have trouble getting to the outpatient clinic every week. This study shows that both kinds of treatments can help acquired brain injury patients with improving social communication, even if it has been a long time since the injury happened.

For more information read the entire article https://pubmed.ncbi.nlm.nih.gov/36966953/

Summarized by Arielle Berkowitz, DO
November 2023

When a player experiences a bump to the head during a sports game or practice, he/she may begin to experience headaches, dizziness, blurred vision, trouble concentrating, or a brief loss of consciousness known as a Sports Related Concussion (SRC). These symptoms are often troubling and may make it difficult to immediately return to school, work, and/or sports. SRC can occur at any age and at any level of athletic training.

Recovery after a SRC is different for each individual. Athletes who are female, who have had prior concussions, learning disabilities, and/or psychiatric illness may have more trouble returning to their normal daily activities. During this tough time, it is important to follow with experts who can help with the recovery process and provide education, guidance, and encouragement.

In the past, it was recommended that athletes who have sustained a SRC completely rest their minds and body- avoiding television, phones, computers, and school-work- so that their brains could fully heal. More recent guidelines advise light activity/work during this recovery period. In most states, athletes are required to progress through a daily exercise schedule with a trained professional for one whole week. During this time, the athlete must perform exercises with increasing intensity with close monitoring of symptoms.

Vestibular therapy is a therapy that is often offered to patients who continue to experience symptoms such as dizziness and balance issues weeks after their injury. With vestibular therapy, patients work closely with physical therapists to improve things such as balance and vision. In a recent article, “Early Initiation of Vestibular Therapy Following Sport-Related Concussions: A Retrospective Cohort Study,” by Ferry et al., the authors wanted to determine whether or not starting vestibular therapy shortly after injury would result in a faster recovery. In this study, the researchers reviewed the medical charts of patients ages 12-25 years who had a SRC between January 2014-December 2019, were seen in the Sports Medicine Concussion Clinic at Duke University and were referred to PT for vestibular therapy.

Results from this study suggested that waiting to start vestibular therapy could increase the time to recovery and return to sport. In other words, starting vestibular therapy early after injury could result in a quicker recovery. After SRC, it is important to seek appropriate care early. Although we still need more details regarding exactly how long a person should receive vestibular therapy, how frequently he/she should go for visits, and when to begin the therapy, it is noted that, overall, it is extremely helpful without any detrimental effects.

For more information view the article https://doi.org/10.7759/cureus.39764