A Case Report on Heart Rate Variability Biofeedback and Postconcussion Syndrome: Healing the Autonomic Nervous System

Postconcussion syndrome is a devastating condition of the mind, body, and even personality. Mounting research demonstrates that heart rate variability biofeedback can help the concussed individual in three critical ways: (a) eliciting high amplitude oscillations in cardiovascular functions and thereby strengthening self-regulatory control mechanisms; (b) restoring autonomic balance; and (c) increasing the afferent impulse stream from the baroreceptors to restore balance between inhibitory and excitatory processes in the brain.

Diffusion and functional MRI findings and their relationship to behaviour in postconcussion syndrome: a scoping review

Postconcussion syndrome (PCS) is a term attributed to the constellation of symptoms that fail to recover after a concussion. PCS is associated with a variety of symptoms such as headaches, concentration deficits, fatigue, depression and anxiety that have an enormous impact on patients’ lives. There is currently no diagnostic biomarker for PCS. There have been attempts at identifying structural and functional brain changes in patients with PCS, using diffusion tensor imaging (DTI) and functional MRI (fMRI), respectively, and relate them to specific PCS symptoms. In this scoping review, we appraised, synthesised and summarised all empirical studies that (1) investigated structural or functional brain changes in PCS using DTI or fMRI, respectively, and (2) assessed behavioural alterations in patients with PCS. We performed a literature search in MEDLINE (Ovid), Embase (Ovid) and PsycINFO (Ovid) for primary research articles published up to February 2020. We identified 8306 articles and included 45 articles that investigated the relationship between DTI and fMRI parameters and behavioural changes in patients with PCS: 20 diffusion, 20 fMRI studies and 5 papers with both modalities. Most frequently studied structures were the corpus callosum, superior longitudinal fasciculus in diffusion and the dorsolateral prefrontal cortex and default mode network in the fMRI literature. Although some white matter and fMRI changes were correlated with cognitive or neuropsychiatric symptoms, there were no consistent, converging findings on the relationship between neuroimaging abnormalities and behavioural changes which could be largely due to the complex and heterogeneous presentation of PCS. Furthermore, the heterogeneity of symptoms in PCS may preclude discovery of one biomarker for all patients. Further research should take advantage of multimodal neuroimaging to better understand the brain–behaviour relationship, with a focus on individual differences rather than on group comparisons.

Quick cell-free DNA testing for the prediction of postconcussion syndrome: a single-center prospective pilot trial

OBJECTIVE Mild traumatic brain injury (mTBI) is a major cause of emergency room (ER) admission. Thirty percent of mTBI patients have postconcussion syndrome (PCS), and 15% have symptoms for over a year. This population is underdiagnosed and does not receive appropriate care. The authors proposed a fast and inexpensive fluorometric measurement of circulating cell-free DNA (cfDNA) as a biomarker for PCS. cfDNA is a proven, useful marker of a variety of acute pathological conditions such as trauma and acute illness. METHODS Thirty mTBI patients were recruited for this prospective single-center trial. At admission, patients completed questionnaires and blood was drawn to obtain cfDNA. At 3–4 months after injury, 18 patients returned for cognitive assessments with questionnaires and the Color Trails Test (CTT). The fast SYBR Gold assay was used to measure cfDNA. RESULTS Seventeen men and 13 women participated in this trial. The mean ± SD age was 50.9 ± 13.9 years. Of the 18 patients who returned for cognitive assessment, one-third reported working fewer hours, 4 (22.2%) changed their driving patterns, and 5 (27.7%) reduced or stopped performing physical activity. The median cfDNA level of the mTBI group was greater than that of the matched healthy control group (730.5 vs 521.5 ng/ml, p = 0.0395). Admission cfDNA concentration was negatively correlated with performance on the CTT1 and CTT2 standardized tests (r = −0.559 and −0.599), meaning that greater cfDNA level was correlated with decreased cognitive performance status. The performance of the patients with normal cfDNA level included in the mTBI group was similar to that of the healthy participants. In contrast, the increased cfDNA group (> 800 ng/ml) had lower scores on the CTT tests than the normal cfDNA group (p < 0.001). Furthermore, patients with moderate/severe cognitive impairment according to CTT1 results had a greater median cfDNA level than the patients with scores indicating mild impairment or normal function (1186 vs 473.5 ng/ml, p = 0.0441, area under the receiver operating characteristic curve = 0.8393). CONCLUSIONS The data from this pilot study show the potential to use cfDNA, as measured with a fast test, as a biomarker to screen for PCS in the ER. A large-scale study is required to establish the value of cfDNA as an early predictor of PCS.

Effect of repetitive transcranial magnetic stimulation on depression and cognition in individuals with traumatic brain injury: a systematic review and meta-analysis

Repetitive transcranial magnetic stimulation (rTMS) is an FDA-approved therapy in major depressive disorder. However, its treatment efficacy on depression after traumatic brain injury (TBI) remains inconclusive. We conducted a meta-analysis to assess the effectiveness of executing rTMS over dorsolateral prefrontal cortex (DLPFC) on depression, cognitive impairment and post-concussion syndrome in individuals with traumatic brain injury. This study contained seven randomized controlled trials that published before April 5, 2020 in PubMed, Embase, Scopus, Cochrane, and Web of Science databases. The rTMS had significant anti-depressant effect (SMD = 1.03, p = 0.02), but the effects dissipated at 1-month follow-up (SMD = 0.39, p = 0.62). In the subgroup analysis, only applying rTMS to left DLPFC area of post-TBI patients showed significant anti-depressant effect (SMD = 0.98, p = 0.04). Moreover, current data observed that rTMS on post-TBI patients possessed substantial improvement in visuospatial memory (SMD = 0.39, p < 0.0001), but wasn’t in processing speed (SMD = − 0.18, p = 0.32) and selective attention (SMD = 0.21, p = 0.31). In addition, the effect of rTMS is not superior to sham on postconcussion syndrome. In conclusion, the short-term antidepressant effect of left DLPFC rTMS in patients with TBI was significant. However, the effectiveness of rTMS on cognition and postconcussion syndrome in patients with post-TBI depression was limited.

Implementation of Biofeedback Interventions for the Treatment of Adults With Postconcussion Syndrome

Date Presented Accepted for AOTA INSPIRE 2021 but unable to be presented due to online event limitations. Participants with postconcussion syndrome were taught breathing exercises and given a heart rate variability (HRV) monitor to promote reduced anxiety. Outcome measures included the Perceived Stress Scale, HRV, and anxiety tracking. Each measure improved for participants by the study's conclusion. Primary Author and Speaker: Kelsee Hove Contributing Authors: Callie Lodden, Emily Mock, Mariah Roe, Lindsey Schulz, and Jillian Jones

Clinical Evaluation and Treatment of Patients with Postconcussion Syndrome

Postconcussion syndrome (PCS) is a complex set of symptoms occurring in a small percentage of patients following concussion. The condition is characterized by headaches, dizziness, cognitive difficulties, somatosensory issues, and a variety of other symptoms with varying durations. There is a lack of objective markers and standard treatment protocols. With the complexity created by premorbid conditions, psychosomatic issues, secondary gains, and litigations, providers often find themselves in a tough situation in the care of these patients. This article combines literature review and clinical insights with a focus on the underlying pathophysiology of PCS to provide a roadmap for evaluating and treating this condition.

Osteopathic manipulative medicine in the management of headaches associated with postconcussion syndrome

Context Previous studies have demonstrated the effectiveness of osteopathic manipulative treatment (OMT) for various headache types, with limited evidence of its use for headaches related to mild traumatic brain injury (MTBI). No studies prior studies were found regarding OMT for headaches in patients with postconcussion syndrome (PCS), defined as symptom persistence for longer than 3 months after MTBI. Objectives To evaluate OMT for headaches in patients with PCS. Methods A controlled pilot study was conducted of patients with PCS who presented to an outpatient interdisciplinary rehabilitation clinic; patients with symptoms lasting longer than 3 months were enrolled and randomly assigned to an OMT treatment group or a control group. Primary outcome measures were immediate change in headache scores according to a Visual Analog Scale (VAS) and change in the six item Headache Impact Test (HIT-6) between baseline and follow up visits. The participants in the control group completed the HIT-6 between baseline and follow up visits but did not receive OMT and did not complete the VAS. Mean immediate VAS score change for the treatment group and mean improvement in HIT-6 scores for both groups between baseline and follow up were analyzed for statistical significance. Results A total of 26 patients were included in this study: 13 (50%) in the treatment group and 13 (50%) in the control group. Six patients (23.1%), three from each group, did not complete the study, so 10 subjects in each group were included in the final analysis. Statistically significant improvement in VAS scores was seen immediately after OMT in the treatment group (mean change, 2.1;p=0.002). Mean HIT-6 scores showed improvement in the treatment group compared with the control group, although the change was not statistically significant (p=0.15) from baseline to follow up visit. No adverse effects from treatments were noted. Conclusions Patients with headaches secondary to PCS showed immediate benefit in headache pain intensity after OMT. However, no sustained benefit was found on the follow up visit compared with the control group.