Publications by authors named "Ross D Zafonte"

110 Publications

Athlete Enjoyment of Prior Education Moderates change in Concussion-Reporting Intention after Interactive Education.

Inquiry 2021 Jan-Dec;58:469580211022641

Stanford School of Medicine, Palo Alto, CA, USA.

Undiagnosed concussions increase risk of additional injuries and can prolong recovery. Because of the difficulties recognizing concussive symptoms, concussion education must specifically target improving athlete concussion reporting. Many concussion education programs are designed without significant input from athletes, resulting in a less enjoyable athlete experience, with potential implications on program efficacy. Athlete enjoyment of previous concussion education programs moderates the improvement in concussion-reporting intention after experiencing the research version of CrashCourse (CC) concussion education. Prospective cohort study. Level of evidence: Level IV. Quantitative assessment utilizing ANOVA with moderation analysis of 173 male high school football players, aged 13 to 17, who completed baseline assessments of concussion knowledge, concussion reporting, and attitudes about prior educational interventions. Athletes were subsequently shown CC, before a follow-up assessment was administered assessing the same domains. At baseline, only 58.5% of athletes reported that they enjoyed their previous concussion education. After CC, athletes were significantly more likely to endorse that they would report a suspected concussion (from 69.3% of athletes to 85.6%;  < .01). Enjoyment of previous concussion education moderated concussion-reporting intention after CC ( = .02), with CC having a greater effect on concussion-reporting intention in athletes with low enjoyment of previous concussion education ( = 0.21,  = .02), than on individuals with high enjoyment of previous concussion education ( = .99). Enjoyment of CC did not have a moderating effect on concussion-reporting intention. Athletes who previously did not enjoy concussion education exhibited greater gains in concussion-reporting intention than athletes who enjoyed previous education. Given the potential risks associated with undiagnosed concussions, concussion education has sought to improve concussion reporting. Because most athletes participate in concussion education programs due to league or state mandates, improving concussion-reporting intention in these low-enjoyment athletes is of particular relevance to improving concussion-reporting intention broadly.
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http://dx.doi.org/10.1177/00469580211022641DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8170270PMC
May 2021

Variation in 30-Day Readmission Rates from Inpatient Rehabilitation Facilities to Acute Care Hospitals.

J Am Med Dir Assoc 2021 May 11. Epub 2021 May 11.

Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Research Institute, Charlestown, MA, USA. Electronic address:

Objectives: To quantify the rate of readmission from inpatient rehabilitation facilities (IRFs) to acute care hospitals (ACHs) during the first 30 days of rehabilitation stay. To measure variation in 30-day readmission rate across IRFs, and the extent that patient and facility characteristics contribute to this variation.

Design: Retrospective analysis of an administrative database.

Setting And Participants: Adult IRF discharges from 944 US IRFs captured in the Uniform Data System for Medical Rehabilitation database between October 1, 2015 and December 31, 2017.

Methods: Multilevel logistic regression was used to calculate adjusted rates of readmission within 30 days of IRF admission and examine variation in IRF readmission rates, using patient and facility-level variables as predictors.

Results: There were a total of 104,303 ACH readmissions out of a total of 1,102,785 IRFs discharges. The range of 30-day readmission rates to ACHs was 0.0%‒28.9% (mean = 8.7%, standard deviation = 4.4%). The adjusted readmission rate variation narrowed to 2.8%‒17.5% (mean = 8.7%, standard deviation = 1.8%). Twelve patient-level and 3 facility-level factors were significantly associated with 30-day readmission from IRF to ACH. A total of 82.4% of the variance in 30-day readmission rate was attributable to the model predictors.

Conclusions And Implications: Fifteen patient and facility factors were significantly associated with 30-day readmission from IRF to ACH and explained the majority of readmission variance. Most of these factors are nonmodifiable from the IRF perspective. These findings highlight that adjusting for these factors is important when comparing readmission rates between IRFs.
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http://dx.doi.org/10.1016/j.jamda.2021.03.033DOI Listing
May 2021

Working against bias: double blind peer review at .

J Osteopath Med 2021 04 16;121(5):451-453. Epub 2021 Apr 16.

Journal of Osteopathic Medicine, American Osteopathic Association, Chicago, IL, USA.

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http://dx.doi.org/10.1515/jom-2021-0097DOI Listing
April 2021

Evidence based management of sports related concussion.

J Osteopath Med 2021 04 9;121(5):499-502. Epub 2021 Apr 9.

Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, MA, USA.

Sports related concussion (SRC) is a common condition evaluated by healthcare professionals. In an article entitled "Return to Play After Concussion: Clinical Guidelines for Young Athletes" published in the December 2019 issue of the , guidelines for the management of SRC were presented to assist healthcare professionals in the management of patients with SRC. However, much of the information presented in that article is contradicted by current expert recommendations and evidence based practice guidelines. The management of SRC has evolved to a nuanced, domain driven diagnosis requiring a multidisciplinary treatment team and a customized management plan for each patient to ensure competent treatment of patients with SRC. As such, this Commentary summarizes current recommendations for diagnosis and management of SRC.
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http://dx.doi.org/10.1515/jom-2021-0058DOI Listing
April 2021

Functional outcomes in the inpatient rehabilitation setting following severe COVID-19 infection.

PLoS One 2021 31;16(3):e0248824. Epub 2021 Mar 31.

Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, Massachusetts, United States of America.

Objective: To characterize the functional impairments of a cohort of patients undergoing inpatient rehabilitation after surviving severe COVID-19 illness, in order to better understand the ongoing needs of this patient population.

Methods: This study consisted of a retrospective chart review of consecutive patients hospitalized for COVID-19 and admitted to a regional inpatient rehabilitation hospital from April 29th to May 22nd, 2020. Patient demographics, clinical characteristics and complications from acute hospitalization were examined. Measures of fall risk (Berg Balance Scale), endurance (6 Minute Walk Test), gait speed (10 Meter Walk Test), mobility (transfer and ambulation independence), cognition, speech and swallowing (American Speech and Hearing Association National Outcomes Measurement System Functional Communication Measures) were assessed at rehabilitation admission and discharge.

Results: The study population included 29 patients and was 70% male, 58.6% white and with a mean age of 59.5. The mean length of acute hospitalization was 32.2 days with a mean of 18.7 days intubated. Patients spent a mean of 16.7 days in inpatient rehabilitation and 90% were discharged home. Patients demonstrated significant improvement from admission to discharge in measures of fall risk, endurance, gait speed, mobility, cognition, speech and swallowing, (p< 0.05). At discharge, a significant portion of the population continued to deficits in cognition (attention 37%; memory 28%; problem solving 28%), balance (55%) and gait speed (97%).

Conclusion: Patients admitted to inpatient rehabilitation after hospitalization with COVID-19 demonstrated deficits in mobility, cognition, speech and swallowing at admission and improved significantly in all of these domains by discharge. However, a significant number of patients exhibited residual deficits at discharge highlighting the post-acute care needs of this patient population.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0248824PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8011729PMC
April 2021

Prelude to the special issue on novel neurocircuit, cellular and molecular targets for developing functional rehabilitation therapies of neurotrauma.

Exp Neurol 2021 Jul 18;341:113689. Epub 2021 Mar 18.

Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA; Neurotrauma Recovery Research, Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital Network, Mass General Brigham, and Harvard Medical School, Boston, MA, USA; Spaulding Research Institute, Spaulding Rehabilitation Hospital Network, Boston, MA, USA. Electronic address:

The poor endogenous recovery capacity and other impediments to reinstating sensorimotor or autonomic function after adult neurotrauma have perplexed modern neuroscientists, bioengineers, and physicians for over a century. However, despite limited improvement in options to mitigate acute pathophysiological sequalae, the past 20 years have witnessed marked progresses in developing efficacious rehabilitation strategies for chronic spinal cord and brain injuries. The achievement is mainly attributable to research advancements in elucidating neuroplastic mechanisms for the potential to enhance clinical prognosis. Innovative cross-disciplinary studies have established novel therapeutic targets, theoretical frameworks, and regiments to attain treatment efficacy. This Special Issue contained eight papers that described experimental and human data along with literature reviews regarding the essential roles of the conventionally undervalued factors in neural repair: systemic inflammation, neural-respiratory inflammasome axis, modulation of glutamatergic and monoaminergic neurotransmission, neurogenesis, nerve transfer, recovery neurobiology components, and the spinal cord learning, respiration and central pattern generator neurocircuits. The focus of this work was on how to induce functional recovery from manipulating these underpinnings through their interactions with secondary injury events, peripheral and supraspinal inputs, neuromusculoskeletal network, and interventions (i.e., activity training, pharmacological adjuncts, electrical stimulation, and multimodal neuromechanical, brain-computer interface [BCI] and robotic assistance [RA] devices). The evidence suggested that if key neurocircuits are therapeutically reactivated, rebuilt, and/or modulated under proper sensory feedback, neurological function (e.g., cognition, respiration, limb movement, locomotion, etc.) will likely be reanimated after neurotrauma. The efficacy can be optimized by individualizing multimodal rehabilitation treatments via BCI/RA-integrated drug administration and neuromechanical protheses.
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http://dx.doi.org/10.1016/j.expneurol.2021.113689DOI Listing
July 2021

National Institute of Neurological Disorders and Stroke Consensus Diagnostic Criteria for Traumatic Encephalopathy Syndrome.

Neurology 2021 05 15;96(18):848-863. Epub 2021 Mar 15.

From the Boston University CTE Center (D.I.K.), Department of Neurology, Boston University School of Medicine, Boston; Brain Injury Program (D.I.K.), Encompass Health Braintree Rehabilitation Hospital, Braintree, MA; University of Washington Memory & Brain Wellness Clinic (C.B.), Department of Neurology, University of Washington School of Medicine, Seattle; Department of Neurology (D.W.D., C.H.A.), Mayo Clinic, Scottsdale, AZ; Boston University CTE Center (J.M., M.L.A.), Boston University Alzheimer's Disease Center, Department of Neurology, Boston University School of Medicine; Boston University CTE Center (M.L.M.), Boston University School of Medicine, MA; Departments of Neurology (L.J.B.), Ophthalmology, and Population Health, New York University Grossman School of Medicine; Departments of Neurosciences and Psychiatry University of California San Diego (S.J.B.), La Jolla; Departments of Neurology and Psychiatry (W.B.B.), New York University Grossman School of Medicine; Center for Neuroscience and Regenerative Medicine (D.L.B.), Uniformed Services University of the Health Sciences, Department of Neurology, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Boston University CTE Center (R.C.C.), Boston University Alzheimer's Disease Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, MA; Departments of Rehabilitation Medicine and Neurology (K.D.-O.C.), Icahn School of Medicine, Mount Sinai, New York; Department of Neurology (Y.E.G.), Barrow Neurological Institute, Phoenix, AZ; Rancho Los Amigos National Rehabilitation Center (B.D.J.), Downey, CA; Department of Neurology (B.D.J.), Keck School of Medicine of USC. Los Angeles, CA; Departments of Psychiatry and Neurology (T.W.M.), Indiana University School of Medicine, Indianapolis; Veterans Affairs Northwest Mental Illness (E.R.P.), Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Mayo Clinic Alzheimer's Disease Research Center (R.C.P.), Mayo Clinic, Rochester, MN; Department of Psychiatry and Psychology (J.V.W.), Mayo Clinic, Scottsdale, AZ; Department of Physical Medicine and Rehabilitation (R.D.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston; Faculty of Psychology and Neuroscience (É.M.F.), Maastricht University, the Netherlands, Department of Psychiatry, University of Cambridge, United Kingdom; National Institute of Neurological Disorders and Stroke (D.J.B.), National Institutes of Health; National Institute of Neurological Disorders and Stroke (W.J.K.), Bethesda, MD; Boston University CTE Center (Y.T.), Boston University Alzheimer's Disease Center, Boston University School of Medicine, Department of Biostatistics, Boston University School of Public Health; Boston University CTE Center (A.C.M.), Boston University Alzheimer's Disease Center, Departments of Neurology and Pathology & Laboratory Medicine, Boston University School of Medicine; VA Boston Healthcare System (A.C.M.), US Department of Veteran Affairs, MA; Psychiatry Neuroimaging Laboratory (M.E.S.), Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, University of Nevada School of Integrated Health Sciences; Cleveland Clinic Lou Ruvo Center for Brain Health (J.L.C.), Las Vegas, NV; Banner Alzheimer's Institute (E.M.R.), Arizona State University; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix, AZ; and Boston University CTE Center (R.A.S.), Boston University Alzheimer's Disease Center, Departments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, MA.

Objective: To develop evidence-informed, expert consensus research diagnostic criteria for traumatic encephalopathy syndrome (TES), the clinical disorder associated with neuropathologically diagnosed chronic traumatic encephalopathy (CTE).

Methods: A panel of 20 expert clinician-scientists in neurology, neuropsychology, psychiatry, neurosurgery, and physical medicine and rehabilitation, from 11 academic institutions, participated in a modified Delphi procedure to achieve consensus, initiated at the First National Institute of Neurological Disorders and Stroke Consensus Workshop to Define the Diagnostic Criteria for TES April, 2019. Before consensus, panelists reviewed evidence from all published cases of CTE with neuropathologic confirmation, and they examined the predictive validity data on clinical features in relation to CTE pathology from a large clinicopathologic study (n = 298).

Results: Consensus was achieved in 4 rounds of the Delphi procedure. Diagnosis of TES requires (1) substantial exposure to repetitive head impacts (RHIs) from contact sports, military service, or other causes; (2) core clinical features of cognitive impairment (in episodic memory and/or executive functioning) and/or neurobehavioral dysregulation; (3) a progressive course; and (4) that the clinical features are not fully accounted for by any other neurologic, psychiatric, or medical conditions. For those meeting criteria for TES, functional dependence is graded on 5 levels, ranging from independent to severe dementia. A provisional level of certainty for CTE pathology is determined based on specific RHI exposure thresholds, core clinical features, functional status, and additional supportive features, including delayed onset, motor signs, and psychiatric features.

Conclusions: New consensus diagnostic criteria for TES were developed with a primary goal of facilitating future CTE research. These criteria will be revised as updated clinical and pathologic information and in vivo biomarkers become available.
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http://dx.doi.org/10.1212/WNL.0000000000011850DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8166432PMC
May 2021

Recovery of Consciousness and Functional Outcome in Moderate and Severe Traumatic Brain Injury.

JAMA Neurol 2021 May;78(5):548-557

Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital and Harvard Medical School, Boston.

Importance: Traumatic brain injury (TBI) leads to 2.9 million visits to US emergency departments annually and frequently involves a disorder of consciousness (DOC). Early treatment, including withdrawal of life-sustaining therapies and rehabilitation, is often predicated on the assumed worse outcome of disrupted consciousness.

Objective: To quantify the loss of consciousness, factors associated with recovery, and return to functional independence in a 31-year sample of patients with moderate or severe brain trauma.

Design, Setting, And Participants: This cohort study analyzed patients with TBI who were enrolled in the Traumatic Brain Injury Model Systems National Database, a prospective, multiyear, longitudinal database. Patients were survivors of moderate or severe TBI who were discharged from acute hospitalization and admitted to inpatient rehabilitation from January 4, 1989, to June 19, 2019, at 1 of 23 inpatient rehabilitation centers that participated in the Traumatic Brain Injury Model Systems program. Follow-up for the study was through completion of inpatient rehabilitation.

Exposures: Traumatic brain injury.

Main Outcomes And Measures: Outcome measures were Glasgow Coma Scale in the emergency department, Disability Rating Scale, posttraumatic amnesia, and Functional Independence Measure. Patient-related data included demographic characteristics, injury cause, and brain computed tomography findings.

Results: The 17 470 patients with TBI analyzed in this study had a median (interquartile range [IQR]) age at injury of 39 (25-56) years and included 12 854 male individuals (74%). Of these patients, 7547 (57%) experienced initial loss of consciousness, which persisted to rehabilitation in 2058 patients (12%). Those with persisting DOC were younger; had more high-velocity injuries; had intracranial mass effect, intraventricular hemorrhage, and subcortical contusion; and had longer acute care than patients without DOC. Eighty-two percent (n = 1674) of comatose patients recovered consciousness during inpatient rehabilitation. In a multivariable analysis, the factors associated with consciousness recovery were absence of intraventricular hemorrhage (adjusted odds ratio [OR], 0.678; 95% CI, 0.532-0.863; P = .002) and intracranial mass effect (adjusted OR, 0.759; 95% CI, 0.595-0.968; P = .03). Functional improvement (change in total functional independence score from admission to discharge) was +43 for patients with DOC and +37 for those without DOC (P = .002), and 803 of 2013 patients with DOC (40%) became partially or fully independent. Younger age, male sex, and absence of intraventricular hemorrhage, intracranial mass effect, and subcortical contusion were associated with better functional outcome. Findings were consistent across the 3 decades of the database.

Conclusions And Relevance: This study found that DOC occurred initially in most patients with TBI and persisted in some patients after rehabilitation, but most patients with persisting DOC recovered consciousness during rehabilitation. This recovery trajectory may inform acute and rehabilitation treatment decisions and suggests caution is warranted in consideration of withdrawing or withholding care in patients with TBI and DOC.
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http://dx.doi.org/10.1001/jamaneurol.2021.0084DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7922241PMC
May 2021

Carbamazepine for Irritability and Aggression after Traumatic Brain Injury: A Randomized, Placebo-Controlled Study.

J Neurotrauma 2021 Mar 9. Epub 2021 Mar 9.

Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, Indiana, USA.

This study tested the hypothesis that carbamazepine (CBZ) reduces irritability/aggression among individuals >6 months post-traumatic brain injury (TBI). Seventy individuals were enrolled in a parallel-group, randomized, double-blind, placebo-controlled, forced-titration trial of CBZ ( = 35) versus placebo ( = 35). Participants were randomly assigned to receive CBZ or placebo 42 days with outcome assessed at baseline and Day 42. Dose was titrated up to 400 mg CBZ or placebo equivalent two times daily. Symptoms of irritability and aggression were measured using the Neuropsychiatric Inventory Irritability (NPI-I) and Aggression (NPI-A) domains as a composite measure (NPI-I/A). Global impression of change was recorded from participant, observer, and study clinician. The CBZ group did not differ significantly from the placebo group ( = 0.60 and 0.59 for NPI-I/A observer and participant ratings, respectively). High placebo effects were observed with minimal clinically important difference in observer NPI-I/A 57% in CBZ group and 77% in placebo group ( = 0.09). Findings were similar for participant ratings. Eighteen of 35 had therapeutic CBZ level ≥4. Therapeutic sample analysis revealed similar high placebo response and non-significant differences except clinician ratings favoring CBZ. Non-serious adverse events occurred more frequently in the CBZ group with greater nervous system effects. CBZ up to 400 mg two times daily was not superior to placebo at reducing irritability/aggression according observers and participants. Large placebo effects may have masked the detection of differences. Clinician rating metrics suggest benefit, and thus, CBZ should remain a treatment option for the experienced brain injury clinician. Data are provided that may aid treatment decisions.
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http://dx.doi.org/10.1089/neu.2020.7530DOI Listing
March 2021

Journal of Osteopathic Medicine: a refreshed and refocused publication for our profession.

Authors:
Ross D Zafonte

J Osteopath Med 2021 01;121(1):1-3

Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital , 300 First Avenue , Charlestown , MA, 02129 , USA.

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http://dx.doi.org/10.1515/jom-2020-0303DOI Listing
January 2021

Non-invasive approaches to functional recovery after spinal cord injury: Therapeutic targets and multimodal device interventions.

Exp Neurol 2021 May 14;339:113612. Epub 2021 Jan 14.

Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Mass General Brigham, and Harvard Medical School, Boston, MA, United States. Electronic address:

This paper is an interdisciplinary narrative review of efficacious non-invasive therapies that are increasingly used to restore function in people with chronic spinal cord injuries (SCI). First presented are the secondary injury cascade set in motion by the primary lesion and highlights in therapeutic development for mitigating the acute pathophysiologic process. Then summarized are current pharmacological strategies for modulation of noradrenergic, serotonergic, and dopaminergic neurotransmission to enhance recovery in bench and clinical studies of subacute and chronic SCI. Last examined is how neuromechanical devices (i.e., electrical stimulation, robotic assistance, brain-computer interface, and augmented sensory feedback) could be comprehensively engineered to engage efferent and afferent motosensory pathways to induce neuroplasticity-based neural pattern generation. Emerging evidence shows that computational models of the human neuromusculoskeletal system (i.e., human digital twins) can serve as functionalized anchors to integrate different neuromechanical and pharmacological interventions into a single multimodal prothesis. The system, if appropriately built, may cybernetically optimize treatment outcomes via coordination of heterogeneous biosensory, system output, and control signals. Overall, these rehabilitation protocols involved neuromodulation to evoke beneficial adaptive changes within spared supraspinal, intracord, and peripheral neuromuscular circuits to elicit neurological improvement. Therefore, qualitatively advancing the theoretical understanding of spinal cord neurobiology and neuromechanics is pivotal to designing new ways to reinstate locomotion after SCI. Future research efforts should concentrate on personalizing combination therapies consisting of pharmacological adjuncts, targeted neurobiological and neuromuscular repairs, and brain-computer interfaces, which follow multimodal neuromechanical principles.
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http://dx.doi.org/10.1016/j.expneurol.2021.113612DOI Listing
May 2021

Evaluating the Effect of Concussion Education Programs on Intent to Report Concussion in High School Football.

J Athl Train 2021 Jan 6. Epub 2021 Jan 6.

Lecturer and Adjunct Affiliate, Stanford University, School of Education. email:

Context: Concussion underreporting leads to delays in diagnosis and treatment, prolonging recovery time. Athletes' self-report of concussion symptoms therefore reduces risk.

Objective: Evaluate the efficacy of three concussion education programs in improving concussion-reporting intention.

Design: Randomized controlled clinical trial with assessment immediately and one-month after education.

Setting: Three high schools in California.

Patients Or Other Participants: 118 male football players were randomly assigned to receive concussion education via: CrashCourse (CC), Centers for Disease Control (CDC) video educational materials (Vi), or CDC written educational materials (Wr).

Main Outcome Measures: Concussion-reporting intention was assessed at baseline, immediately after education, and at one-month follow-up. Secondary outcomes included concussion knowledge, attitudes, perceived reporting norms, and perceived behavioral control.

Results: Athletes across all educational formats had significant improvement in concussion-reporting intention immediately following education and at one-month follow-up (mean improvement 6.8% and 11.4%, respectively; p<0.001). Similar findings were observed across all education formats in secondary analyses examining knowledge, attitudes, and perceived behavioral control. However, there were significant differences by education and time (p=0.03). On post-hoc analysis, athletes who received CC had increased concussion-reporting intention immediately and at one-month (baseline=4.7, immediate=6.1, one-month=6.0; p=0.007 compared to significant increases only at one-month for CDC-Vi (baseline=4.3, immediate=5.2, one-month=5.8; p=0.001), and no significant improvement for CDC-Wr (p=0.10). Secondary analyses indicated significant differences between CC and both CDC interventions, in concussion knowledge and attitudes, immediately after education and at one-month. There were no significant differences in perceived behavioral control between-interventions or in perceived concussion-reporting norms across or between interventions.

Conclusion: All athletes exhibited improved intent to report concussions, increased concussion knowledge, better concussion attitudes, and more perceived behavioral control, both immediately after education and at one-month follow-up. However, athletes randomized to CC reported greater intent to report concussion, more knowledge, and improved concussion-reporting attitudes, when compared to CDC-Vi and CDC-Wr.

Trial Registry: ClinicalTrials.gov trial ID number is XXX.
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http://dx.doi.org/10.4085/509-20DOI Listing
January 2021

How Physician Compensation and Education Debt Affects Financial Stress and Burnout: A Survey Study of Women in Physical Medicine and Rehabilitation.

PM R 2020 Dec 10. Epub 2020 Dec 10.

Department of Physical Medicine and Rehabilitation, Harvard Medical School, Massachusetts General Hospital, Brigham and Women's Hospital, Spaulding Rehabilitation Hospital, Boston, MA.

Objective: To investigate the contribution of financial stress to physician burnout and satisfaction among women physiatrists. Relationships among education debt and compensation with demographic, sociologic, and workplace factors were also assessed.

Design: This was a cross-sectional survey study of women physicians in the field of physical medicine and rehabilitation (PM&R) in the United States. The survey consisted of 51 questions covering demographic information (current and maximum education debt, race/ethnicity, years out of training, practice type and setting, hours worked, family structure, and domestic duties), work/life satisfaction, and burnout. The association between current/maximum debt and demographic characteristics, work/life satisfaction, and physician burnout were examined.

Results: Of the 245 U.S. women attending physiatrists who met inclusion criteria, 222 (90.6%) reported ever having education debt (median category $101 000-150 000) and 162 (66.1%) reported current debt (median category ≤ $50 000). Of these participants, 218 (90.5%) agreed that they would have fewer burnout symptoms if they were able to do more work that is core to their professional mission and 226 (92.2%) agreed that feeling undervalued at work is linked to physiatrists' burnout symptoms. Greater debt was seen in those who identified as Black/African American, were fewer years out of training, practiced general physiatry, and had both inpatient and outpatient responsibilities. Greater current debt had a significant relationship with measurements of work/life dissatisfaction. Burnout was associated with higher debt, lower compensation, more hours worked per week, and fewer hours of exercise performed per week.

Conclusions: This study examined women physiatrists' perceptions of financial stress and found that greater education debt was associated with personal life dissatisfaction, career regret, and burnout. Further research is needed to address related causes and solutions.
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http://dx.doi.org/10.1002/pmrj.12534DOI Listing
December 2020

Rehabilitation of Sport-Related Concussion.

Clin Sports Med 2021 Jan;40(1):93-109

UBMD Orthopaedics and Sports Medicine, Concussion Management Clinic and Research Center, State University of New York at Buffalo, 160 Farber Hall, Buffalo, NY 14214, USA. Electronic address:

This article provides a summary of clinical assessment methods and nonpharmacologic rehabilitation techniques used for concussed patients. It describes concussion-relevant physical examination methods to identify underlying symptom generators. This approach allows practitioners to prescribe targeted rehabilitation therapies to treat postconcussion symptoms. Evidence-based rehabilitation approaches include cervical rehabilitation, vestibulo-ocular rehabilitation, and sub-symptom threshold aerobic exercise.
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http://dx.doi.org/10.1016/j.csm.2020.08.003DOI Listing
January 2021

Rehabilitation of Sport-Related Concussion.

Clin Sports Med 2021 Jan;40(1):93-109

UBMD Orthopaedics and Sports Medicine, Concussion Management Clinic and Research Center, State University of New York at Buffalo, 160 Farber Hall, Buffalo, NY 14214, USA. Electronic address:

This article provides a summary of clinical assessment methods and nonpharmacologic rehabilitation techniques used for concussed patients. It describes concussion-relevant physical examination methods to identify underlying symptom generators. This approach allows practitioners to prescribe targeted rehabilitation therapies to treat postconcussion symptoms. Evidence-based rehabilitation approaches include cervical rehabilitation, vestibulo-ocular rehabilitation, and sub-symptom threshold aerobic exercise.
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http://dx.doi.org/10.1016/j.csm.2020.08.003DOI Listing
January 2021

African American Patient Disparities in COVID-19 Outcomes: A Call to Action for Physiatrists to Provide Rehabilitation Care to Black Survivors.

Am J Phys Med Rehabil 2020 11;99(11):986-987

From the Department of Orthopaedics and Rehabilitation, Division of Physiatry, Yale New Haven Hospital and Yale School of Medicine, New Haven, Connecticut (CAO); Sholas Medical Consulting, LLC, New Orleans, Louisiana (MGS); Department of Rehabilitation Medicine, University of Texas Health Science Center San Antonio Long School of Medicine, San Antonio, Texas (MV-G); Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, Massachusetts (RDZ, JKS); Brigham and Women's Hospital, Boston, Massachusetts (RDZ, JKS); and Massachusetts General Hospital, Boston, Massachusetts (RDZ, JKS).

SARS-CoV-2 is a novel and highly contagious coronavirus that has been a major threat to the public's health. As the pandemic has spread across the United States, it has become abundantly clear that vulnerable populations include not only the elderly and individuals with disabilities but also those who are homeless or incarcerated, Latinx Americans, African Americans, and Native Americans. This report is focused on the experience of Black patients, inclusive of African Americans, and recognizes the higher morbidity and mortality in this population. Physiatrists can provide care for the sequelae faced by survivors and prioritize rehabilitation services. Programs must be administered in a way that is geographically accessible to Black communities and demonstrate cultural competence. Future research should focus on the social determinants of health to better understand at-risk populations and improve outcomes.
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http://dx.doi.org/10.1097/PHM.0000000000001568DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7526402PMC
November 2020

Race in association with physical and mental health among former professional American-style football players: findings from the Football Players Health Study.

Ann Epidemiol 2020 11 30;51:48-52.e2. Epub 2020 Jul 30.

Department of Environmental Health, Harvard TH Chan School of Public Health, Boston, MA, USA.

Purpose: Race differences in health are pervasive in the United States. American-style football players are a racially diverse group with social status and other benefits that may reduce health disparities. Whether race disparities in health exist among former professional football players, and whether they differ by era of play, is unknown.

Methods: We examined the association of self-reported race with health outcomes (e.g., physical and cognitive function, pain, depression, and anxiety), among 3747 participants in the Football Players Health Study, comprising former National Football League players who played since 1960. We conducted analyses stratified by age.

Results: Black players had increased risk of all five adverse health outcomes versus white players (risk ratio range = 1.36 to 1.89). Native Hawaiians and men of other races had greater risk of all health outcomes except impaired physical functioning, compared with white players (risk ratio range = 1.25 to 1.64). No clear patterns were observed by era of play. In general, race disparities were not accounted for by health-related exposures during playing years. Adjustment for current BMI somewhat attenuated associations.

Conclusions: Social and economic advantages of playing professional football did not appear to equalize race disparities in health.
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http://dx.doi.org/10.1016/j.annepidem.2020.07.013DOI Listing
November 2020

The ENIGMA sports injury working group:- an international collaboration to further our understanding of sport-related brain injury.

Brain Imaging Behav 2021 Apr;15(2):576-584

H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA.

Sport-related brain injury is very common, and the potential long-term effects include a wide range of neurological and psychiatric symptoms, and potentially neurodegeneration. Around the globe, researchers are conducting neuroimaging studies on primarily homogenous samples of athletes. However, neuroimaging studies are expensive and time consuming, and thus current findings from studies of sport-related brain injury are often limited by small sample sizes. Further, current studies apply a variety of neuroimaging techniques and analysis tools which limit comparability among studies. The ENIGMA Sports Injury working group aims to provide a platform for data sharing and collaborative data analysis thereby leveraging existing data and expertise. By harmonizing data from a large number of studies from around the globe, we will work towards reproducibility of previously published findings and towards addressing important research questions with regard to diagnosis, prognosis, and efficacy of treatment for sport-related brain injury. Moreover, the ENIGMA Sports Injury working group is committed to providing recommendations for future prospective data acquisition to enhance data quality and scientific rigor.
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http://dx.doi.org/10.1007/s11682-020-00370-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7855299PMC
April 2021

Daily acute intermittent hypoxia to improve walking function in persons with subacute spinal cord injury: a randomized clinical trial study protocol.

BMC Neurol 2020 Jul 8;20(1):273. Epub 2020 Jul 8.

Department of Physical Medicine and Rehabilitation, Harvard Medical School, 1575 Cambridge Street, Boston, MA, 02138, USA.

Background: Restoring community walking remains a highly valued goal for persons recovering from traumatic incomplete spinal cord injury (SCI). Recently, studies report that brief episodes of low-oxygen breathing (acute intermittent hypoxia, AIH) may serve as an effective plasticity-inducing primer that enhances the effects of walking therapy in persons with chronic (> 1 year) SCI. More persistent walking recovery may occur following repetitive (weeks) AIH treatment involving persons with more acute SCI, but this possibility remains unknown. Here we present our clinical trial protocol, designed to examine the distinct influences of repetitive AIH, with and without walking practice, on walking recovery in persons with sub-acute SCI (< 12 months) SCI. Our overarching hypothesis is that daily exposure (10 sessions, 2 weeks) to AIH will enhance walking recovery in ambulatory and non-ambulatory persons with subacute (< 12 months) SCI, presumably by harnessing endogenous mechanisms of plasticity that occur soon after injury.

Methods: To test our hypothesis, we are conducting a randomized, placebo-controlled clinical trial on 85 study participants who we stratify into two groups according to walking ability; those unable to walk (non-ambulatory group) and those able to walk (ambulatory group). The non-ambulatory group receives either daily AIH (15, 90s episodes at 10.0% O with 60s intervals at 20.9% O) or daily SHAM (15, 90s episodes at 20.9% O with 60s intervals at 20.9% O) intervention. The ambulatory group receives either 60-min walking practice (WALK), daily AIH + WALK, or daily SHAM+WALK intervention. Our primary outcome measures assess overground walking speed (10-Meter Walk Test), endurance (6-Minute Walk Test), and balance (Timed Up & Go Test). For safety, we also measure levels of pain, spasticity, systemic hypertension, and autonomic dysreflexia. We record outcome measures at baseline, days 5 and 10, and follow-ups at 1 week, 1 month, 6 months, and 12 months post-treatment.

Discussion: The goal of this clinical trial is to reveal the extent to which daily AIH, alone or in combination with task-specific walking practice, safely promotes persistent recovery of walking in persons with traumatic, subacute SCI. Outcomes from this study may provide new insight into ways to enhance walking recovery in persons with SCI.

Trial Registration: ClinicalTrials.gov, NCT02632422 . Registered 16 December 2015.
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http://dx.doi.org/10.1186/s12883-020-01851-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7341658PMC
July 2020

Modifiable Risk Factors for Poor Cognitive Function in Former American-Style Football Players: Findings from the Harvard Football Players Health Study.

J Neurotrauma 2021 01 4;38(2):189-195. Epub 2020 Aug 4.

Department of Environmental Health, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA.

Recent attention to consequences of head trauma among former professional American-style football players has increased the likelihood that former players and their healthcare providers attribute neurocognitive effects to these exposures. In addition to head trauma, however, many potentially modifiable risk factors are associated with cognitive impairment. We examined the association of self-reported risk factors for cognitive impairment (e.g., cardiovascular health, sleep, pain, depression, anxiety, smoking, physical impairment, and physical activity) with cognition-related quality of life, measured by the Quality of Life in Neurological Disorders, Applied Cognition-General Concerns (Neuro-QOL) among 3803 former National Football League (NFL) players. We examined the prevalence of risk factors among men who had experienced a high number of concussion symptoms during playing years, comparing men with good current cognition-related QOL, the "healthy concussed," to men with poor cognition-related QOL, the "unhealthy concussed." Physical functioning, pain, depression, and anxiety were very strongly associated with poor cognitive-related QOL (risk ratio range, 2.21-2.70,  < 0.0001 for all). Short sleep duration and low physical activity were also strongly associated (RR = 1.69 and 1.57, respectively,  < 0.0001 for both). The largest differences between healthy and unhealthy concussed were in chronic pain (72.0% vs. 21.2%), depressive symptoms (50.3% vs. 6.3%), anxiety symptoms (53.4% vs. 11.6%), and physical impairment (52.4% vs. 12.5%). Substantial differences also existed in prevalence of sleep apnea, short sleep duration, high-intensity exercise, weight training, high blood pressure, and body mass index ≥35 kg/m (all differences >10 percentage points). We identified cognitive risk factors, including chronic pain, mood problems, sleep problems, obesity, and lack of exercise, that were commonly present in former football players with cognition-related impairment. Better treatment for these factors may reduce cognitive problems in this population.
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http://dx.doi.org/10.1089/neu.2020.7070DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8182470PMC
January 2021

Neurological Manifestation of COVID-19 and the Enhanced Role of Physiatrists.

Am J Phys Med Rehabil 2020 09;99(9):858-859

From the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts (MAI, AST, RDZ, JKS, JH, SP); Brigham and Women's Hospital, Boston, Massachusetts (RDZ, JKS, SP); and Massachusetts General Hospital, Boston, Massachusetts (MAI, RDZ, JKS, JH).

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http://dx.doi.org/10.1097/PHM.0000000000001502DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7315833PMC
September 2020

Assessing the Ability of Comorbidity Indexes to Capture Comorbid Disease in the Inpatient Rehabilitation Spinal Cord Injury Population.

Arch Phys Med Rehabil 2020 10 27;101(10):1731-1738. Epub 2020 May 27.

Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA; Harvard Medical School, Boston, MA.

Objective: To examine whether commonly used comorbidity indexes (Deyo-Charlson comorbidity index, Elixhauser comorbidity index, the Centers for Medicare and Medicaid Services [CMS] comorbidity tiers) capture comorbidities in the acute traumatic and nontraumatic SCI inpatient rehabilitation population.

Design: Retrospective cross-sectional study.

Participants: Data were obtained from the Uniform Data System for Medical Rehabilitation from October 1, 2015 to December 31, 2017 for adults with spinal cord injury (SCI) (Medicare-established Impairment Group Codes 04.110-04.230, 14.1, 14.3). This study included SCI discharges (N=66,235) from 833 inpatient rehabilitation facilities.

Main Outcome Measures: International Classification of Diseases-10th Revision-Clinical Modifications (ICD-10-CM) codes were used to assess 3 comorbidity indexes (Deyo-Charlson comorbidity index, Elixhauser comorbidity index, CMS comorbidity tiers). The comorbidity codes that occurred with >1% frequency were reported. The percentages of discharges for which no comorbidities were captured by each comorbidity index were calculated.

Results: Of the total study population, 39,285 (59.3%) were men and 11,476 (17.3%) were tetraplegic. The mean number of comorbidities was 14.7. There were 13,939 distinct ICD-10-CM comorbidity codes. There were 237 comorbidities that occurred with >1% frequency. The Deyo-Charlson comorbidity index, Elixhauser comorbidity index, and the CMS tiers did not capture comorbidities of 58.4% (95% confidence interval, 58.08%-58.84%), 29.4% (29.07%-29.76%), and 66.1% (65.73%-66.46%) of the discharges in our study, respectively, and 28.8% (28.42%-29.11%) of the discharges did not have any comorbidities captured by any of the comorbidity indexes.

Conclusion: Commonly used comorbidity indexes do not reflect the extent of comorbid disease in the SCI rehabilitation population. This work suggests that alternative measures may be needed to capture the complexity of this population.
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http://dx.doi.org/10.1016/j.apmr.2020.04.025DOI Listing
October 2020

Minimum Competency Recommendations for Programs That Provide Rehabilitation Services for Persons With Disorders of Consciousness: A Position Statement of the American Congress of Rehabilitation Medicine and the National Institute on Disability, Independent Living and Rehabilitation Research Traumatic Brain Injury Model Systems.

Arch Phys Med Rehabil 2020 06 20;101(6):1072-1089. Epub 2020 Feb 20.

Concussion Care Centre of Virginia and Tree of life Services, Henrico, VA; Virginia Commonwealth University, Department of Physical Medicine and Rehabilitation, Richmond, VA.

Persons who have disorders of consciousness (DoC) require care from multidisciplinary teams with specialized training and expertise in management of the complex needs of this clinical population. The recent promulgation of practice guidelines for patients with prolonged DoC by the American Academy of Neurology, American Congress of Rehabilitation Medicine (ACRM), and National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) represents a major advance in the development of care standards in this area of brain injury rehabilitation. Implementation of these practice guidelines requires explication of the minimum competencies of clinical programs providing services to persons who have DoC. The Brain Injury Interdisciplinary Special Interest Group of the ACRM, in collaboration with the Disorders of Consciousness Special Interest Group of the NIDILRR-Traumatic Brain Injury Model Systems convened a multidisciplinary panel of experts to address this need through the present position statement. Content area-specific workgroups reviewed relevant peer-reviewed literature and drafted recommendations which were then evaluated by the expert panel using a modified Delphi voting process. The process yielded 21 recommendations on the structure and process of essential services required for effective DoC-focused rehabilitation, organized into 4 categories: diagnostic and prognostic assessment (4 recommendations), treatment (11 recommendations), transitioning care/long-term care needs (5 recommendations), and management of ethical issues (1 recommendation). With few exceptions, these recommendations focus on infrastructure requirements and operating procedures for the provision of DoC-focused neurorehabilitation services across subacute and postacute settings.
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http://dx.doi.org/10.1016/j.apmr.2020.01.013DOI Listing
June 2020

Amantadine and memantine: a comprehensive review for acquired brain injury.

Brain Inj 2020 02 20;34(3):299-315. Epub 2020 Feb 20.

Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

This comprehensive review discusses clinical studies of patients following brain injuries (traumatic, acquired, or stroke), who have been treated with amantadine or memantine. Both amantadine and memantine are commonly used in the acute rehabilitation setting following brain injuries, despite their lack of FDA-approval for neuro-recovery. Given the broad utilization of such agents, there is a need to review the evidence supporting this common off-label prescribing. The purpose of this review is to describe the mechanisms of action for memantine and amantadine, as well as to complete a comprehensive review of the clinical uses of these agents. We included 119 original, clinical research articles from NCBI Medline, published before 2019. We focused on the domains of neuroplasticity, functional recovery, motor recovery, arousal, fatigue, insomnia, behavior, agitation, and cognition. Most of the existing research supporting the use of amantadine and memantine in recovery from brain injuries was done in very small populations, limiting the significance of conclusions. While most studies are positive; small effect sizes are usually reported, or populations are subject to bias. Furthermore, evidence is so limited that this review includes research regarding both acute and chronic acquired brain injury populations. Fortunately, reported short-term side effects generally are modest, and stop soon after amantadine/memantine is discontinued. However, responses are inconsistent, and the phenotype of responders remains elusive.
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http://dx.doi.org/10.1080/02699052.2020.1723697DOI Listing
February 2020

Neurocognitive markers of childhood abuse in individuals with PTSD: Findings from the INTRuST Clinical Consortium.

J Psychiatr Res 2020 02 23;121:108-117. Epub 2019 Nov 23.

Department of Psychiatry, University of California San Diego, La Jolla, CA, 92093, USA; University of California, San Diego Department of Family Medicine and Public Health, La Jolla, CA, 92093, USA.

To date, few studies have evaluated the contribution of early life experiences to neurocognitive abnormalities observed in posttraumatic stress disorder (PTSD). Childhood maltreatment is common among individuals with PTSD and is thought to catalyze stress-related biobehavioral changes that might impact both brain structure and function in adulthood. The current study examined differences in brain morphology (brain volume, cortical thickness) and neuropsychological performance in individuals with PTSD characterized by low or high self-reported childhood maltreatment, compared with healthy comparison participants. Data were drawn from the INjury and TRaUmatic STress (INTRuST) Clinical Consortium imaging repository, which contains MRI and self-report data for individuals classified as PTSD positive (with and without a history of mild traumatic brain injury [mTBI]), individuals with mTBI only, and healthy comparison participants. The final sample included 36 individuals with PTSD without childhood maltreatment exposure (PTSD, n = 30 with mTBI), 31 individuals with PTSD and childhood maltreatment exposure (PTSD + M, n = 26 with mTBI), and 114 healthy comparison participants without history of childhood maltreatment exposure (HC). The PTSD + M and PTSD groups demonstrated cortical thinning in prefrontal and occipital regions, and poorer verbal memory and processing speed compared to the HC group. PTSD + M participants demonstrated cortical thinning in frontal and cingulate regions, and poorer executive functioning relative to the PTSD and HC groups. Thus, neurocognitive features varied between individuals with PTSD who did versus did not have exposure to childhood maltreatment, highlighting the need to assess developmental history of maltreatment when examining biomarkers in PTSD.
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http://dx.doi.org/10.1016/j.jpsychires.2019.11.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7568209PMC
February 2020

Geriatric rehabilitation.

Handb Clin Neurol 2019 ;167:531-543

Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, United States; Massachusetts General Hospital, Boston, MA, United States; Brigham and Women's Hospital, Boston, MA, United States; Boston Veterans Administration, Boston, MA, United States; Harvard Medical School, Boston, MA, United States. Electronic address:

Rehabilitation of elderly persons is accompanied by unique challenges, as the physiologic changes with aging may be compounded by a multitude of psychologic, social, and genetic factors. In this chapter we present an overview of the impairments that develop with aging. We discuss factors to consider when evaluating a patient with functional complaints and opportunities for treatment. We provide an overview of common injuries encountered in the elderly, prognostication, and general strategies employed for rehabilitation. New treatment options and areas of ongoing research are also discussed.
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http://dx.doi.org/10.1016/B978-0-12-804766-8.00029-7DOI Listing
April 2020

Rethinking Medical Journal Club.

Am J Med 2020 05 16;133(5):534-535. Epub 2019 Nov 16.

Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, Mass.

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http://dx.doi.org/10.1016/j.amjmed.2019.10.033DOI Listing
May 2020

Self-Reported Cognitive Function and Mental Health Diagnoses among Former Professional American-Style Football Players.

J Neurotrauma 2020 04 10;37(8):1021-1028. Epub 2019 Dec 10.

Football Players' Health Study at Harvard University, Harvard Medical School, Boston, Massachusetts.

Clinical practice strongly relies on patients' self-report. Former professional American-style football players are hesitant to seek help for mental health problems, but may be more willing to report cognitive symptoms. We sought to assess the association between cognitive symptoms and diagnosed mental health problems and quality of life among a cohort of former professional players. In a cross-sectional design, we assessed self-reported cognitive function using items from the Quality of Life in Neurological Disorders (Neuro-QOL) Item Bank. We then compared mental health diagnoses and quality of life, assessed by items from the Patient-Reported Outcome Measurement Information System (PROMIS), between former professional players reporting daily problems in cognitive function and former players not reporting daily cognitive problems. Of the 3758 former professional players included in the analysis, 40.0% reported daily problems due to cognitive dysfunction. Former players who reported daily cognitive problems were more likely to also report depression (18.0% vs. 3.3%, odds ratio [OR] = 6.42, 95% confidence interval [CI] [4.90-8.40]) and anxiety (19.1% vs. 4.3%, OR = 5.29, 95% CI [4.14-6.75]) than those without daily cognitive problems. Further, former players reporting daily cognitive problems were more likely to report memory loss and attention deficit(/hyperactivity) disorder and poorer general mental health, lower quality of life, less satisfaction with social activities and relationships, and more emotional problems. These findings highlight the potential of an assessment of cognitive symptoms for identifying former players with mental health, social, and emotional problems.
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http://dx.doi.org/10.1089/neu.2019.6661DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7185350PMC
April 2020

Huperzine A for the treatment of cognitive, mood, and functional deficits after moderate and severe TBI (HUP-TBI): results of a Phase II randomized controlled pilot study: implications for understanding the placebo effect.

Brain Inj 2020 22;34(1):34-41. Epub 2019 Oct 22.

Department of Physical Medicine Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA.

: To investigate the effect of Huperzine A on memory and learning in individuals with moderate-severe traumatic brain injury (TBI).: Randomized, double-blind, placebo-controlled Phase II clinical trial.: Subjects were randomly assigned to receive Huperzine A or placebo for 12 weeks and were assessed during in-person visits at screening/baseline, and 6, 12, 24, and 52 weeks post-injury. Changes in memory and learning scores on the California Verbal Learning Test - 2nd Edition (CVLT-II) from baseline to week 12 were assessed using permutation tests and regression analyses.: There was no difference between the Huperzine A and placebo groups in memory performance after 12 weeks of treatment. In the placebo group, significant improvements were noted in learning and memory scores. Both groups showed clinically important improvements in depression on the Beck Depression Index.: The clinically important improvements in cognitive and emotional outcomes observed in both the placebo and active treatment arms of this clinical trial of Huperzine A are best understood in the context of a placebo effect. Future trials involving patients with moderate-severe TBI in the subacute to chronic phases of recovery should be designed to account for placebo effects as failure to do so may lead to spurious conclusions.
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http://dx.doi.org/10.1080/02699052.2019.1677941DOI Listing
October 2019

Exposure to American Football and Neuropsychiatric Health in Former National Football League Players: Findings From the Football Players Health Study.

Am J Sports Med 2019 10 30;47(12):2871-2880. Epub 2019 Aug 30.

Investigation performed at Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.

Background: Former American football players have a higher prevalence of cognitive impairment than that of the US general population. It remains unknown what aspects of playing football are associated with neuropsychiatric outcomes.

Hypothesis: It was hypothesized that seasons of professional football, playing position, and experience of concussions were associated with cognition-related quality of life (QOL) and indicators of depression and anxiety.

Study Design: Descriptive epidemiology study.

Methods: The authors examined whether seasons of professional football, playing position, and experience of concussions, as measured by self-report of 10 symptoms, were associated with cognition-related QOL and indicators of depression and anxiety in a cross-sectional survey conducted 2015 to 2017. Cognition-related QOL was measured by the short form of the Quality of Life in Neurological Disorders: Applied Cognition-General Concerns. The Patient Health Questionnaire-4 measured depression and anxiety symptoms. Of 13,720 eligible men with apparently valid contact information, 3506 players returned a questionnaire at the time of this analysis (response rate = 25.6%).

Results: Seasons of professional play (risk ratio [RR] per 5 seasons = 1.19, 95% CI = 1.06-1.34) and playing position were associated with cognition-related QOL. Each 5 seasons of play was associated with 9% increased risk of indicators of depression at borderline statistical significance ( = .05). When compared with former kickers, punters, and quarterbacks, men who played any other position had a higher risk of poor cognition-related QOL, depression, and anxiety. Concussion symptoms were strongly associated with poor cognition-related QOL (highest concussion quartile, RR = 22.3, < .001), depression (highest quartile, RR = 6.0, < .0001), and anxiety (highest quartile, RR = 6.4, < .0001), even 20 years after last professional play.

Conclusion: The data suggest that seasons of play and playing position in the NFL are associated with lasting neuropsychiatric health deficits. Additionally, poor cognition-related QOL, depression, and anxiety appear to be associated with concussion in the long term.
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http://dx.doi.org/10.1177/0363546519868989DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7163246PMC
October 2019