Faculty Bibliography

Sports-related concussion, is a serious neurological concern that many adolescent athletes will face during their athletic careers. In some instances, the effects of sports-related head injury are long-lasting. Due to their still-developing brains, adolescents appear to be more vulnerable to long-term repercussions of these injuries. As all sports-related concussions are mild traumatic brain injuries (mTBI), this review we will examine the pathophysiology of mTBI, its acute effects and long-term risks from sustaining injury, and current and needed advancements in the areas of neuropsychological testing, accelerometer telemetry, and neuroimaging. Current methods do not adequately measure the extent of an injury that an athlete may sustain, potentially putting these athletes at a much greater risk for long-term effects. To better understand mTBI, neuropsychological testing best practices need to be developed, standardized, and implemented based on sound scientific evidence in order to be propagated as clinical guidelines. Wearable accelerometers can be used to assess thresholds for mTBI and cumulative effects of concussive and subconcussive injuries. Novel neuroimaging methods that can detect anatomical abnormalities and functional deficits with more specificity and sensitivity should be developed. Young athletes are particularly a vulnerable population warranting immediate and significant research aimed at protecting them against sports related injury and mitigating their long-term deficits.

Phantom limb pain (PLP) following amputation, which is experienced by the vast majority of amputees, has been reported to be relieved with daily sessions of mirror therapy. During each session, a mirror is used to view the reflected image of the intact limb moving, providing visual feedback consistent with the movement of the missing/phantom limb. To investigate potential neural correlates of the treatment effect, we measured brain responses in volunteers with unilateral leg amputation using functional magnetic resonance imaging (fMRI) during a four-week course of mirror therapy. Mirror therapy commenced immediately following baseline scans, which were repeated after approximately two and four week intervals. We focused on responses in the region of sensorimotor cortex corresponding to primary somatosensory and motor representations of the missing leg. At baseline, prior to starting therapy, we found a strong and unexpected response in sensorimotor cortex of amputees to visually presented images of limbs. This response was stronger for images of feet compared to hands and there was no such response in matched controls. Further, this response to visually presented limbs was no longer present at the end of the four week mirror therapy treatment, when perceived phantom limb pain was also reduced. A similar pattern of results was also observed in extrastriate and parietal regions typically responsive to viewing hand actions, but not in regions corresponding to secondary somatosensory cortex. Finally, there was a significant correlation between initial visual responsiveness in sensorimotor cortex and reduction in PLP suggesting a potential marker for predicting efficacy of mirror therapy. Thus, enhanced visual responsiveness in sensorimotor cortex is associated with PLP and modulated over the course of mirror therapy.

Neurocognitive computerized assessment tools (NCATs) were developed to assist military clinicians with the tracking of recovery from injury and return to full duty decisions with a recent focus on the setting of post-concussion evaluations. However, there is limited data on the impact of deployment on neurocognitive functioning, sleepiness, and mood in healthy, non-concussed Service members. Automated Neuropsychological Assessment Metrics version 4 TBI Military (ANAM) data was obtained for a sample of active duty deployed personnel (n = 72) without recent history of mild traumatic brain injury (mTBI). A linear regression was conducted to examine the effects of sleepiness and mood state on neurocognitive performance. The overall multivariate regression was statistically significant. Negative mood states were the most salient predictors of neurocognitive performance with higher levels of endorsement associated with lower scores. The findings support measures of negative mood state, but not sleepiness, as relevant predictors of neurocognitive performance as measured by the ANAM. These results indicate that mood needs to be considered when reviewing neurocognitive data to ensure that appropriate clinical decisions are made; in particular for return-to-duty decisions in deployed settings after concussion recovery.

In order to better understand how to identify and treat student-athletes who experience concussions, better insight into reporting behavior of athletes is needed. This study aims to identify information influencing athletes' attitudes toward reporting their concussions and the perceived trajectory of their recovery both athletically and academically. Twenty-five former high school and collegiate athletes who experienced concussions in a wide variety of sports, organizational levels, and time periods gave insight through structured, qualitative interviews. A number of factors regarding education about concussions, proper diagnosis of concussions, and motivational pressures within high school and collegiate athletics were assessed. Eight major themes were identified regarding the participants' experiences with sport-related concussion: optimism bias, invisibility of the injury, diagnostic barriers, desire to play, external support and pressures, uncertainty of long-term prognosis, generational factors, and protection of future athletes. The findings support that underreporting of concussions among those players interviewed is related to misperceived risk, lack of education, and a struggle between internal and external pressures to play through injury. However, those who did seek medical and academic support, often did receive the necessary aid.

Following amputation, most amputees still report feeling the missing limb and often describe these feelings as excruciatingly painful. Phantom limb sensations (PLS) are useful while controlling a prosthesis; however, phantom limb pain (PLP) is a debilitating condition that drastically hinders quality of life. Although such experiences have been reported since the early 16th century, the etiology remains unknown. Debate continues regarding the roles of the central and peripheral nervous systems. Currently, the most posited mechanistic theories rely on neuronal network reorganization; however, greater consideration should be given to the role of the dorsal root ganglion within the peripheral nervous system. This Review provides an overview of the proposed mechanistic theories as well as an overview of various treatments for PLP.

Adolescents are at high risk for sustaining concussions. There is considerable controversy regarding the sensitivity of neurocognitive tests to detect and track dysfunction in the aftermath of concussion. Two neurocognitive test batteries were compared during the subacute phase of recovery from concussion to determine sensitivity to concussion. Adolescents (ages 11-17 years) with a concussion diagnosis (eight males, seven females, 9-69 days after injury) were recruited through a concussion clinic and compared with community nonconcussed volunteers (11 males, three females). Adolescents completed the online version of the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) on a desktop computer and the Defense Automated Neurobehavioral Assessment (DANA) on a handheld device, as well as the Grooved Pegboard Test, which assessed manual dexterity and motor speed. There were no differences in self-reported symptoms on the Post-Concussion Symptom Scale comparing concussed and nonconcussed adolescents. No significant between-groups differences were observed in ImPACT performance. Performance deficits were apparent for the DANA assessment, reflecting lower throughput scores for simple reaction time and response inhibition parameters in those with concussion. Concussed adolescents also had slower Grooved Pegboard Test performance when using the nondominant hand. Both the DANA test battery and the Grooved Pegboard Test appear to have promise as tools to detect persistent cognitive and motor dysfunction in the subacute period after concussion.

Mild traumatic brain injury (mTBI) is a common occurrence, with over 3 million cases reported every year in the United States. While research into the underlying pathophysiology is ongoing, there is an urgent need for better clinical guidelines that allow more consistent diagnosis of mTBI and ensure safe return-to-play timelines for athletes, nonathletes, and military personnel. The development of a suite of biomarkers that indicate the pathogenicity of mTBI could lead to clinically useful tools for establishing both diagnosis and prognosis. Here, we review the current evidence for mTBI biomarkers derived from investigations of the multifactorial pathology of mTBI. While the current literature lacks the scope and size for clarification of these biomarkers' clinical utility, early studies have identified some promising candidates.