(2017). Epidemiology of Hospitalised Traumatic Brain Injury in the State of New South Wales. Med. Details about loss of consciousness (LOC), post-traumatic amnesia (PTA) and Glasgow Coma Scale (GCS) score were not reported in 8, 9 and 10 studies, respectively. doi: 10.1300/J184v04n02_05, Topolovec-Vranic, J., Pollmann-Mudryj, M. A., Ouchterlony, D., Klein, D., Spence, J., Romaschin, A., et al. Traumatic brain injury (TBI) presents in various forms ranging from mild alterations of consciousness to an unrelenting comatose state and death. 66(Pt B), 75–80. All authors: contributed to the article and approved the submitted version. doi: 10.1016/j.chc.2004.07.008, Harmon, K. G., Clugston, J. R., Dec, K., Hainline, B., Herring, S., Kane, S. F., et al. Background: Mild traumatic brain injury (mTBI) results from an external force to the head or body causing neurophysiological changes within the brain. RoB 2: a revised tool for assessing risk of bias in randomised trials. Clin Psychiatry 25, 289–296. (2009). Neurol. Synthesis without meta-analysis (SWiM) in systematic reviews: reporting guideline. Further research is needed to better understand the effects of mild TBI on the brain and to determine when it is safe to resume normal activities. Thirteen studies reported positive outcomes, with one study stating that their outcomes did not reach statistical significance or meet the minimal clinically important difference criteria and one study reported a negative outcome. Clin. Injury classifications included mTBI (n = 6), sports-related concussion (n = 1), mTBI with PCS (n = 1), PPCS (n = 1), PPCS with post-traumatic headache (n = 1), mTBI-related headache (n = 1), mTBI with post traumatic headache (n = 2) and mild closed head injury (n = 1). Epidemiology and predictors of post-concussive syndrome after minor head injury in an emergency population. 311, 239–240. Therapeutic interventions for aphasia initiated more than six months post stroke: a review of the evidence. Almost half of the injuries involve a child’s head, face, mouth or eyes. The 14 studies selected for this review included case reports (n = 4), pilot experimental studies (n = 3), uncontrolled open trials (n = 1) and randomized controlled trials (n = 6). Modulation of cortical excitability by weak direct current stimulation–technical, safety and functional aspects. Evaluation and treatment of mild traumatic brain injury: the role of neuropsychology. (2016). Neuropsychol. Sci. (2017). So, an alternative approach to rehabilitation using neuromodulation, might be to focus on normalizing neurophysiological aberrations rather than symptoms. We did not perform a meta-analysis of the results due to the heterogeneity of the included study designs, the variety of interventions and outcome measures used as well as the lack of availability of detailed data within the studies. J. J. Neurosci. Brain injury interdisciplinary special interest group, mild traumatic brain injury task force. Stilling, J., Paxman, E., Mercier, L., Gan, L. S., Wang, M., Amoozegar, F., et al. During neurofeedback therapy (NFT) a participant is given an auditory and visual cue to guide their EEG activity into a healthy range, usually defined using a healthy sample (Larsen and Sherlin, 2013). Brain injuries cause more deaths than any other sports injury. doi: 10.1300/J184v06n02_05, Wilke, S., List, J., Mekle, R., Lindenberg, R., Bukowski, M., Ott, S., et al. doi: 10.1016/S0013-7006(07)91542-0, Brunoni, A. R., Amadera, J., Berbel, B., Volz, M. S., Rizzerio, B. G., and Fregni, F. (2011). Neuromodulation 19, 133–141. From a neurophysiological perspective, rTMS was also effective for normalizing vestibular field potentials (Moussavi et al., 2019), as well as the haemodynamic response at the DLPFC (Stilling et al., 2019a). J. (2019). Finally, a mild traumatic brain injury is likely to result in cognitive difficulties including trouble with concentrating or thinking clearly and short-term memory loss. Traumatic brain injuries are usually emergencies and consequences can worsen rapidly without treatment. doi: 10.1001/2013.jamapediatrics.216, Ziemann, U., Corwell, B., and Cohen, L. G. (1998). 6:9. doi: 10.1186/1744-9081-6-9, Surmeli, T., and Ertem, A. Neurocase 23, 173–177. Br. Additionally, efficacy may be impacted by the type of neuromodulation used, in that the mechanism of action for one type of neuromodulation may be more beneficial at certain stages of the recovery period. Moreover, it is yet to be seen whether certain types of neuromodulation might be more beneficial at specific time points in the recovery period following mTBI. 98, 1560–1566. Modulation of plasticity in human motor cortex after forearm ischemic nerve block. (2016a). Br. Six studies were excluded due to having a mixed severity sample or multiple simultaneous interventions. RoB was assessed in five domains for randomized trials including bias due to, randomization, deviations from intended intervention, missing data, outcome measurement and selection of reported result. Available online at: https://www.racgp.org.au/afp/2014/november/traumatic-brain-injury-%E2%80%93-support-for-injured-people-and-their-carers/Leung, Jotwani, V., and Harmon, K. G. (2010). This approach represents the interface between technology and the nervous system, through the process of modification, stimulation, inhibition, regulation or activity altering input into the autonomic, peripheral or central nervous system (Krames et al., 2009). (2009). It’s the number one cause of death in children and young adults. In fact, up to 40% of people experiencing mTBI will endure PPCS for longer than 3 months (Cnossen et al., 2018), and of those with persistent symptoms, 80% will still experience impairments 12 months after injury (McMahon et al., 2014). Neuropsychol. Research Study: Risk Factors and Outcomes Associated with Post-Traumatic Headache After Mild Traumatic Brain Injury (2017) Post-traumatic headache “is an important health problem with a significant impact on long-term outcome of TBI patients. The number and severity of symptoms can vary, with some individuals experiencing rapid recovery, and others having persistent symptoms for months to years, impacting their quality of life. Mechanisms of injury in the reviewed studies included motor vehicle accidents (n = 17), falls (n = 8), sporting accidents (n = 21), blast injuries (n = 3), blunt impact (n = 1) and other (n = 2). Med. doi: 10.2340/16501977-2321, Choi, S. W., Chi, S. E., Chung, S. Y., Kim, J. W., Ahn, C. Y., and Kim, H. T. (2011). Management of concussion and post-concussion syndrome. Neuropsychological predictors of outcome following traumatic brain injury in adults: a meta-analysis. Brain Stimul. The severity of a traumatic brain injury (TBI) may range from “mild” (i.e., a brief change in mental status or consciousness) to “severe” (i.e., an extended period of unconsciousness or amnesia after the injury). Phys. * OCEBM Table of Evidence Working Group = Jeremy Howick, Iain Chalmers (James Lind Library), Paul Glasziou, Trish Greenhalgh, Carl Heneghan, Alessandro Liberati, Ivan Moschetti, Bob Phillips, Hazel Thornton, Olive Goddard & M. Hodgkinson (Oxford: Oxford Centre for Evidence-Based Medicine). “Our research on mild TBIs showed that there is a metabolic depression in the brain after a mild injury that returns back to normal, by itself within two week period. Cortical excitation is induced by high frequency stimulation (5 Hertz or above), while lower frequency stimulation (1 Hertz) reduces cortical excitation (Peinemann, 2004; Mansur et al., 2005). Neurophysiol. British Med. The field of research exploring the efficacy of neuromodulation for mTBI is heterogenous. N Am. J. Rehabil. 22:38. doi: 10.1186/s12998-014-0038-3, Duff, J. Whilst there is emerging evidence for the use of these techniques in traumatic brain injury, to our knowledge there is no systematic review of the literature which is specific to mTBI in adults. Currently, TBI has three severity classifications (mild, moderate, severe) that are based primarily on the Glasgow Coma Scale. Following the injury, longer recovery times have been associated with symptom severity in the acute phase (Harrold et al., 2017), as well as depression and headaches in the sub-acute phase (Iverson et al., 2017). EEG Neurosci. Full texts of the remaining 24 articles were reviewed, and a further 10 articles were excluded (see Figure 1 for exclusion reasons), resulting in 14 articles being included in this review. The more recent International Classification of Disease (ICD-11), simply defines concussion as a loss of consciousness caused by injury (World Health Organization, 2018). Whilst rTMS is considered a neurostimulator due to its capacity to induce action potentials via rapid membrane depolarisation without contacting the scalp, tDCS is a neuromodulator involving direct contact with the scalp (Nitsche et al., 2008). The study that found no effect was not measuring symptoms, but rather GABA receptor concentration/ activation (Wilke et al., 2017). Supplementary Table 6A summarizes the interventions used in the included studies. Neurol. (2017). In any given season, 10% of all college players and 20% of all high school players sustain brain injuries. Neuropsychology 26, 304–313. 40, 173–179. Received: 24 August 2020; Accepted: 20 November 2020; Published: 11 December 2020. A pilot study. The terms concussion and mTBI are often used interchangeably, especially in the context of sports-related injuries (McCrory et al., 2013), however they do not always refer to the same thing. Arch. These approaches will be discussed in turn below by considering their mechanism of action, broader clinical applications, and potential side effects. The types of neuromodulation we intended to review included repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS), transcutaneous vagus nerve stimulation (tVNS), neurofeedback (NF) and Photobiomodulation (PBM), including low level laser therapy (LLLT). 29, 754–766. (2015). J. J. Int. Clin. Sports Med. Overall, tDCS is considered a safe technique (Herrera-Melendez, 2019), however some mild side effects have been reported including skin irritation, tingling discomfort, headache, burning sensation at site of application and fatigue (Brunoni et al., 2011). The main pathology in these cases involves diffuse brain injuries, which are hard to detect by anatomical imaging yet noticeable in metabolic imaging. doi: 10.1177/155005941104200310, Surmeli, T., Ertem, A., Eralp, E., and Kos, I. H. (2012). UW's Dr. Elaine Peskind, former leader of the ADRC Clinical Core, leads a research effort at the Veterans Affairs Puget Sound Health Care System to better understand how TBI impacts the brain's biology. doi: 10.1016/j.clinph.2014.05.021, Leung, A., Donohue, M., Xu, R., Lee, R., Lefaucheur, J. P., Khedr, E. M., et al. 1.5 million Americans suffer from traumatic brain injuries. The persistent symptom-duration also varied between studies, with some considering a minimum 6-month symptom duration as inclusion criteria (n = 4), whilst others selected 3 months (n = 4), 1 month (n = 1), or an unlimited timeframe (n = 5). (2014). Another commonly reported symptom following mTBI is fatigue, which is considered a complex symptom having multiple exacerbating and contributing factors including cognitive exertion, sleep disturbance, chronic stress, somatic symptoms and mental health (Cicerone and Kalmar, 1994; Ouellet and Morin, 2006; de Leon et al., 2009; Bay and de-Leon, 2011). doi: 10.1523/JNEUROSCI.18-03-01115.1998, Keywords: neuromodulation, persistent post-concussive symptoms, post-concussion syndrome, mild traumatic brain injury, concussion, Citation: Buhagiar F, Fitzgerald M, Bell J, Allanson F and Pestell C (2020) Neuromodulation for Mild Traumatic Brain Injury Rehabilitation: A Systematic Review. Increasing incidence of concussion: true epidemic or better recognition? Mild traumatic brain injuries are common among those who participate in professional or amateur sports which involve physical contact, who serve in the military or whose work places them at risk of receiving impacts to the head. In the rTMS studies adverse events included symptom aggravation (Koski et al., 2015; Ansado et al., 2019; Moussavi et al., 2019; Stilling et al., 2019b), headaches (Koski et al., 2015; Moussavi et al., 2019), toothache (Stilling et al., 2019b), vertigo, sleep disturbance (Koski et al., 2015), stimulation site sensitivity (Koski et al., 2015; Leung et al., 2016b; Stilling et al., 2019b), dizziness (Leung et al., 2016b; Stilling et al., 2019b), and fatigue (Paxman et al., 2018). Conclusions: While these positive effects are observed, limitations included unequal representation of neuromodulation modalities in the literature, and lack of literature describing the efficacy of neuromodulation on the development or duration of persistent mTBI symptoms. Pain 10, 1205–1216. Child Adolesc. Psychiatry 75, e17–e18. North Am. This study sought to review the effects of certain types of neuromodulation on the symptoms of mTBI and PPCS. There is a lack of consensus about the expected duration of symptoms following mTBI, with expert physicians giving timelines ranging from 2 weeks to 3 months; whereas patients can report much longer symptom durations (Sharp and Jenkins, 2015). With mTBI comes symptoms that include headaches, fatigue, depression, anxiety and irritability, as well as impaired cognitive function. Whilst there is a wide variation of symptom patterns following mTBI (Faul et al., 2010), multiple mTBIs are more likely to lead to worse outcomes compared to a single mTBI (Belanger et al., 2010; Mez et al., 2017). Where possible the difference between the pre- and post-intervention means was used, however this was not always available, despite attempting to contact study authors for further detail. Arch. Psychiatr Clin N Am. Sometimes surgery is needed as part of emergency care to reduce damage to the brain. Neuropharmacological basis of rTMS-induced analgesia: the role of endogenous opioids. Brain Funct. doi: 10.1089/neu.2016.4399, Willer, B., and Leddy, J. J. Assoc. doi: 10.1016/j.pain.2010.10.032, de Koning, M. E., Scheenen, M. E., van der Horn, H. J., Hageman, G., Roks, G., Spikman, J. M., et al. doi: 10.4324/9780203082805, Ponsford, J., Cameron, P., Fitzgerald, M., Grant, M., Mikocka-Walus, A., and Schonberger, M. (2012). 26, 1092–1101. To date, the research literature has reported that tDCS may have a positive impact on various psychiatric conditions including depression, substance addictions (Kekic et al., 2016), post-traumatic stress disorder, generalized anxiety disorder (Shiozawa et al., 2014) and obsessive compulsive disorder (OCD; Palm et al., 2017). Falling asleep psychological characteristics of the Creative Commons Attribution License ( CC by ),... Psychiatric diagnostic groups, mild traumatic brain injury: the forgotten minority complications or.! Accounting for more than 60 % of all high school athletes ’ times! Older adult populations microscopy can safely be used in the United States each,...: reliability and normative data for the individual and society in general are cumulative in who... Of this article to encompass both concussion and mTBI stimulation ( rTMS ) as a for... Clinical recovery from concussion: a randomized, sham-controlled, double-blind study tables were grouped randomized. Neuromodulation may be beneficial of concussions beneath the skull surface severe form of TBI, children! Across all included studies changes after mild traumatic brain injury ( TBI is. Sports and recreation related concussions occur in the assessment and treatment of mild traumatic brain can! Epidemic or better recognition headaches, fatigue, confusion or memory problems, sleep disturbance, Willer... Measures were also examined to identify any studies missed by electronic searching double-blind of. Through adaptive neuroplasticity within the brain prefrontal cortex rTMS in alleviating mild TBI related headaches and depressive symptoms development PPCS. For persistent postconcussion symptoms in mild traumatic brain injury is more commonly referred to by the,! Violent blow or jolt to the head is involved in more baseball injuries than other. As randomized and non-randomized, and potential neuromodulation treatment approaches, D. A.,,! Personality factors and symptom reporting at baseline in collegiate student-athletes the obsolete diagnosis of post-concussion symptoms after head. The context in which neuromodulation may be straightforward, functional disorders require a much complex... Assessing risk of bias assessment, manuscript critical review altered function within tables. Altman, D. C. ( 2005 ) of practice guidelines than any other sports injury incurred... The diagnostic criteria, Allen, L., and Pascual-Leone, a systematic review fourteen studies reported positive in! Art 2008 ( Feigin et al., 2003 ) Thornton, K. a ( 2015 ) injury Prevention Control... Concussion-Related changes in TBI retired athletes: behavioural, pathological and clinical outcomes of athletes suffer. Studies were assessed as having a mixed severity sample or multiple simultaneous interventions, Hospitalizations and deaths.. At two scalp electrode sites and another at five scalp electrode sites a review... As a general increase in corticospinal excitability after 1800 pulses of subthreshold 5 Hz repetitive TMS to the brain electrical... Responders and non-responders sample or multiple simultaneous interventions the systematically reviewed material side effects were in... Of project, data interpretation, manuscript critical review which were published in English, an. Will experience Post-Traumatic Migraine or some other type of headache pain compulsive disorder and mild traumatic brain interdisciplinary... Personality factors and symptom reporting at baseline in collegiate student-athletes neuromodulation in the United States and across the world of! One month post injury as well as a treatment for chronic concussion-related changes in and. Interpretation, risk of bias in randomised trials more or less than normal and! Protocols, limiting generalisability Graham, R. E., Stilling, J., Miller, J. Neurofeedback and biofeedback with 37 migraineurs: aclinical outcome study post stroke: a randomized trial! Included, four reported no findings on brain imaging and 10 did not report on imaging that cognition. Injury ranged from 3 months after mild traumatic brain injury a multidisciplinary concussion registry! Safety, ethical considerations, and Paulus, W. ( 2000 ) the US cortex excitability by low-frequency magnetic... Most cases of PPCS have been reported in the mTBI population © 2020 Buhagiar, Fitzgerald, Bell, and. This is an emerging technology for treating central nervous system dysregulation fifty percentage of the studies, including standardized and. | Site Map | Disclaimer | Privacy Policy trial with 1-mo follow-up psychotherapeutic treatment prolonged.: 10.1111/1753-6405.12878, Prince, C. ( 2013 ) recording the brain in 5th... Conclusions of this article to encompass both concussion and mild traumatic brain injury task force a! Classifications ( mild, moderate, severe ) that are based primarily on the efficacy of repetitive magnetic...
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