The benefits of exercise for outcome improvement following traumatic brain injury: Evidence, pitfalls and future perspectives

Feasibility and acceptability of an adapted peer-based walking intervention for adults with moderate-to-severe traumatic brain injury

PURPOSE

To examine the feasibility and acceptability of a 6-week peer-based walking intervention for adults with moderate-to-severe TBI with telehealth supports.

MATERIALS AND METHODS

Pre-post feasibility trial with 18 community-dwelling adults (10 men; 8 women) with moderate-to-severe TBI aged 21-61 years (M = 40.6, SD = 11.3). Feasibility outcomes included participation, attrition, safety across 12 90-minute sessions, and telehealth platform quality. Acceptability outcomes included program satisfaction. Exploratory outcomes included daily step count with activity trackers and pre-post intervention questionnaires (mood, leisure satisfaction, exercise self-efficacy, quality of life) through video conferencing.

RESULTS

15/18 (83%) participants completed ≥ 9 sessions (75%). Three participants were lost to attrition. No major adverse events reported. Minor events included fatigue and muscle soreness. Participants reported high satisfaction (M = 9.2/10, SD = 0.9). Average weekly steps per day rose from 10,011 to 11,177 steps (12%). Three participants' step count data were not included due to tremors or forgetting to wear the device (≥ 9 days). One major and several minor connectivity problems occurred. Wilcoxon Signed Ranks tests identified a significant change in negative affect (p < 0.002).

CONCLUSIONS

Findings support the feasibility and acceptability of a 6-week peer-based walking intervention with telehealth supports for our sample.

Barriers and enablers to physical activity for individuals living with traumatic brain injury: a mixed methods systematic review

BACKGROUND

Despite well-documented benefits of physical activity (PA), people with brain injury face numerous PA barriers. This mixed methods systematic review aimed to summarize barriers and enablers that individuals with traumatic brain injury (TBI) experience when participating in PA.

METHODS

Primary studies investigating barriers and/or enablers to PA in adults living with TBI were included. Literature search in MEDLINE, EmCare, Embase, PsychINFO, PEDro, and OTSeeker was initially conducted in December 2021 and January 2022, and updated in June 2022. Methodological quality of the included studies was assessed using Joanna Briggs Institute critical appraisal tools. A customized data extraction form was utilized. Descriptive synthesis was used to summarize the findings.

RESULTS

Twelve studies of various methodological qualities were identified. Barriers to PA included personal issues, changing health status, external factors, lack of support, and lack of knowledge. Identified enablers included personal drivers, social support, professional support, accessibility, and education.

CONCLUSIONS

The shared similarities between barriers and enablers across several themes suggest that multiple barriers may be amenable to change. Given the diverse barriers to PA, health professionals should use person-centered, holistic approach with ongoing review and monitoring, when engaging with individuals with TBI.

Enhancing axonal myelination: Clemastine attenuates cognitive impairment in a rat model of diffuse traumatic brain injury

Traumatic brain injury (TBI) has a significant impact on cognitive function, affecting millions of people worldwide. Myelin loss is a prominent pathological feature of TBI, while well-functioning myelin is crucial for memory and cognition. Utilizing drug repurposing to identify effective drug candidates for TBI treatment has gained attention. Notably, recent research has highlighted the potential of clemastine, an FDA-approved allergy medication, as a promising pro-myelinating drug. Therefore, in this study, we aim to investigate whether clemastine can enhance myelination and alleviate cognitive impairment following mild TBI using a clinically relevant rat model of TBI. Mild diffuse TBI was induced using the Closed-Head Impact Model of Engineered Rotational Acceleration (CHIMERA). Animals were treated with either clemastine or an equivalent volume of the vehicle from day 1 to day 14 post-injury. Following treatment, memory-related behavioral tests were conducted, and myelin pathology in the cortex and hippocampus was assessed through immunofluorescence staining and ProteinSimple® capillary-based immunoassay. Our results showed that TBI leads to significant myelin loss, axonal damage, glial activation, and a decrease in mature oligodendrocytes in both the cortex and hippocampus. The TBI animals also exhibited notable deficits in memory-related tests. In contrast, animals treated with clemastine showed an increase in mature oligodendrocytes, enhanced myelination, and improved performance in the behavioral tests. These preliminary findings support the therapeutic value of clemastine in alleviating TBI-induced cognitive impairment, with substantial clinical translational potential. Our findings also underscore the potential of remyelinating therapies for TBI.

Impact of menopause-associated frailty on traumatic brain injury

Navigating menopause involves traversing a complex terrain of hormonal changes that extend far beyond reproductive consequences. Menopausal transition is characterized by a decrease in estradiol-17β (E2), and the impact of menopause resonates not only in the reproductive system but also through the central nervous system, musculoskeletal, and gastrointestinal domains. As women undergo menopausal transition, they become more susceptible to frailty, amplifying the risk and severity of injuries, including traumatic brain injury (TBI). Menopause triggers a cascade of changes leading to a decline in muscle mass, accompanied by diminished tone and excitability, thereby restricting the availability of irisin, a crucial hormone derived from muscles. Concurrently, bone mass undergoes reduction, culminating in the onset of osteoporosis and altering the dynamics of osteocalcin, a hormone originating from bones. The diminishing levels of E2 during menopause extend their influence on the gut microbiota, resulting in a reduction in the availability of tyrosine, tryptophan, and serotonin metabolites, affecting neurotransmitter synthesis and function. Understanding the interplay between menopause, frailty, E2 decline, and the intricate metabolisms of bone, gut, and muscle is imperative when unraveling the nuances of TBI after menopause. The current review underscores the significance of accounting for menopause-associated frailty in the incidence and consequences of TBI. The review also explores potential mechanisms to enhance gut, bone, and muscle health in menopausal women, aiming to mitigate frailty and improve TBI outcomes.

Non-pharmacological interventions for traumatic brain injury

Heterogeneity and variability of symptoms due to the type, site, age, sex, and severity of injury make each case of traumatic brain injury (TBI) unique. Considering this, a universal treatment strategy may not be fruitful in managing outcomes after TBI. Most of the pharmacological therapies for TBI aim at modifying a particular pathway or molecular process in the sequelae of secondary injury rather than a holistic approach. On the other hand, non-pharmacological interventions such as hypothermia, hyperbaric oxygen, preconditioning with dietary adaptations, exercise, environmental enrichment, deep brain stimulation, decompressive craniectomy, probiotic use, gene therapy, music therapy, and stem cell therapy can promote healing by modulating multiple neuroprotective mechanisms. In this review, we discussed the major non-pharmacological interventions that are being tested in animal models of TBI as well as in clinical trials. We evaluated the functional outcomes of various interventions with an emphasis on the links between molecular mechanisms and outcomes after TBI.

The Temporal Relationship Between Moderate to Vigorous Physical Activity and Secondary Conditions During the First Year After Moderate to Severe Traumatic Brain Injury

OBJECTIVE

To determine the cross-sectional and temporal relationships between minutes per week of moderate to vigorous physical activity (MVPA) as measured by a wrist-worn accelerometer and secondary conditions in the first year after moderate to severe traumatic brain injury (TBI).

DESIGN

Prospective longitudinal cohort study.

SETTING

Four inpatient rehabilitation centers.

PARTICIPANTS

Individuals (N = 180) with moderate-severe TBI enrolled in the TBI Model Systems Study.

INTERVENTIONS

Participants wore a wrist accelerometer for 7 days immediately post discharge, and for 7 consecutive days at 6- and 12-months post injury.

MAIN OUTCOME MEASURES

Minutes per week of MVPA from daily averages based on wrist worn accelerometer. Secondary conditions included depression (Patient Health Questionnaire-9), fatigue (PROMIS Fatigue), Pain (Numeric Rating Scale), Sleep (Pittsburgh Sleep Quality Index), and cognition (Brief Test of Adult Cognition by Telephone).

RESULTS

At baseline, 6 and 12 months, 61%, 70% and 79% of the sample achieved at least 150 minutes per week of MVPA. The correlations between minutes of MVPA between baseline, 6 and 12 months were significant (r = 0.53-0.73), as were secondary conditions over these time points. However, no significant correlations were observed between minutes of MVPA and any secondary outcomes cross-sectionally or longitudinally at any time point.

CONCLUSIONS

Given the robust relationships physical activity has with outcomes in the general population, further research is needed to understand the effect of physical activity in individuals with moderate-severe TBI.

The long-term exercise after traumatic brain injury: Reharmonizing brain by sound body

Traumatic brain injuries (TBI) refer to multiple acquired dysfunctions arising from damage to the brain caused by an external force, including rapid acceleration/deceleration and concussion. Among them, mild TBI (mTBI) accounts for most cases (up to 90%) of injuries. It is responsible for a variety of symptoms, including anxiety, depression, and cognitive impairments that remain difficult to be treated. It has been reported that regular physical activity, as well as, improving life quality, display a neuroprotective function, suggesting a possible role in post-traumatic rehabilitation. In this study, we investigated the effects of treadmill exercise in a mice mTBI model by behavioural, electrophysiological and neurochemical analysis. Daily exercise decreased anxiety, aggressive behavior, and depression in mTBI mice. Accordingly, electrophysiological and neurochemical maladaptive rearrangement occurring in the hippocampus of mTBI mice were prevented by the exercise.

Environmental modifications to rehabilitate social behavior deficits after acquired brain injury: What is the evidence?

Social behavior deficits are a common, debilitating consequence of traumatic brain injury and stroke, particularly when sustained during childhood. Numerous factors influence the manifestation of social problems after acquired brain injuries, raising the question of whether environmental manipulations can minimize or prevent such deficits. Here, we examine both clinical and preclinical evidence addressing this question, with a particular focus on environmental enrichment paradigms and differing housing conditions. We aimed to understand whether environmental manipulations can ameliorate injury-induced social behavior deficits. In summary, promising data from experimental models supports a beneficial role of environmental enrichment on social behavior. However, limited studies have considered social outcomes in the chronic setting, and few studies have addressed the social context specifically as an important component of the post-injury environment. Clinically, limited high-caliber evidence supports the use of specific interventions for social deficits after acquired brain injuries. An improved understanding of how the post-injury environment interacts with the injured brain, particularly during development, is needed to validate the implementation of rehabilitative interventions that involve manipulating an individuals' environment.

Exploring a peer-based physical activity program in the community for adults with moderate-to-severe traumatic brain injury

PRIMARY OBJECTIVE

To explore the experiences of program mentors, participants, and employees involved in a peer-based physical activity (PA) program for adults with moderate-to-severe TBI, being piloted by a community fitness center, to develop the program as a measurable intervention.

RESEARCH DESIGN

We adopted an exploratory case study approach through an interpretivist paradigm, which focused on discovering realities about the peer-based PA program across the study participants' views, backgrounds, and experiences.

METHODS AND PROCEDURES

Semi-structured focus groups and individual interviews were conducted with nine adult program participants (3 peer mentors, 6 participants), and three program employees. Inductive content analysis was used to develop themes about their perceived experiences.

MAIN OUTCOMES AND RESULTS

44 open-codes were grouped into 10 subthemes and three final themes: 1) program impacts identified the importance of the program in daily life and resulting psychological, physical, and social outcomes; 2) program characteristics highlighted program leaders, accessibility, and social inclusion; 3) program sustainability included program adherence, benefits for the center, and the program's future.

CONCLUSIONS

Perceptions of program experiences and outcomes identified how peer-based PA for adults with moderate-to-severe TBI can lead to meaningful activities, functioning better, and buy-in from all parties. Implications for research and practice related to supporting health-related behaviors after TBI through group-based, autonomy-supporting approaches are discussed.

How to boost the effects of exercise to favor traumatic brain injury outcome

Physical rehabilitation is an effective therapy to normalize weaknesses encountered with neurological disorders such as traumatic brain injury (TBI). However, the efficacy of exercise is limited during the acute period of TBI because of metabolic dysfunction, and this may further compromise neuronal function. Here we discuss the possibility to normalize brain metabolism during the early post-injury convalescence period to support functional plasticity and prevent long-term functional deficits. Although BDNF possesses the unique ability to support molecular events involved with the transmission of information across nerve cells through activation of its TrkB receptor, the poor pharmacokinetic profile of BDNF has limited its therapeutic applicability. The flavonoid derivative, 7,8-dihydroxyflavone (7,8-DHF), signals through the same TrkB receptors and results in the activation of BDNF signaling pathways. We discuss how the pharmacokinetic limitations of BDNF may be avoided by the use of 7,8-DHF, which makes it a promising pharmacological agent for supporting activity-based rehabilitation during the acute post-injury period after TBI. In turn, docosahexaenoic acid (C22:6n-3; DHA) is abundant in the phospholipid composition of plasma membranes in the brain and its action is important for brain development and plasticity. DHA is a major modulator of synaptic membrane fluidity and function, which is fundamental for supporting cell signaling and synaptic plasticity. Exercise influences DHA function by normalizing DHA content in the brain, such that the collaborative action of exercise and DHA can be instrumental to boost BDNF function with strong therapeutic potential for reducing the deleterious effects of TBI on synaptic plasticity and cognition.

Participatory co-creation of an adapted physical activity program for adults with moderate-to-severe traumatic brain injury

Background

Research about using physical activity (PA) to improve health, quality of life, and participation after moderate-to-severe traumatic brain injury (TBI) is receiving growing attention. However, best-practices for maintaining PA participation after TBI have yet to be defined. In this context, a team of researchers and stakeholders with a moderate-to-severe TBI (including program participants and peer mentors) participated in a co-creation process to optimize a 9-month, 3-phased, community-based, adapted PA program named TBI-Health.

Purpose

The study aimed to provide a detailed account of the participation in and co-creation of a new TBI-Health Program to enhance sport and exercise participation for adults with moderate-to-severe TBI. Specifically, we carried out an in-depth exploration of the perceived experiences and outcomes of users over one cycle of the program to assist the co-creation process.

Methods

An interpretive case study approach was used to explore the experiences and outcomes of the participatory co-creation within and across phases of the TBI-Health program. A purposeful sample of fourteen adults with moderate-to-severe TBI (program participants n = 10; peer mentors n = 4) were involved in audio-recorded focus groups after each program phase. Reflexive thematic analyses within and across the phases identified three higher-order themes.

Results

Program Participation included barriers, facilitators, sources of motivation and suggested modifications to optimize the program; Biopsychosocial Changes highlighted perceived physical, psychological, and social outcomes, by self and others, that resulted from program participation; PA Autonomy emphasized transitions in knowledge, sex- and gender-related beliefs, and abilities related to exercise and sport participation.

Conclusions

Study findings suggest the TBI-Health program can increase autonomy for and reduce barriers to PA for adults with moderate-to-severe TBI, which results in increased PA participation and important physical, psychological, and social benefits. More research is needed about the TBI-Health program with larger samples.