Efficacy of aerobic and resistance exercises on cancer pain: A meta-analysis of randomised controlled trials

Purpose

To evaluate effects of aerobic and resistance exercises for cancer-related pain in adults with and surviving cancer. Secondary objectives were to a) evaluate the effect of exercise on fatigue, psychological function, physical function, b) assess fidelity to exercise.

Design

A systematic search of MEDLINE, EMBASE, AMED, CINAHL and Cochrane Central Register of Controlled Trials was conducted to identify randomised controlled trials (RCTs) comparing aerobic and/or resistance exercise to control groups. The primary endpoint were changes in cancer-related pain intensity from baseline to post intervention. Meta-regression analysis evaluated predictors for heterogeneity between study findings. Tolerability was defined as reporting of exercise-induced adverse events while fidelity evaluated by reported intervention dropout.

Results

Twenty-three RCTs including 1954 patients (age 58 ± 8.5 years; 78 % women); 1087 (56 %) and 867 (44 %) allocated to aerobic/resistance exercise therapy and control group, respectively. Exercise therapy was associated with small to moderate decreases in cancer-related pain compared to controls (SMD = 0.38, 95 % CI: 0.17, 0.58). Although there was significant heterogeneity between individual and pooled study effects (Q = 205.25, p < 0.0001), there was no publication bias. Meta-regression including supervision, age, duration and exercise type as moderators showed no significant differences in reported outcomes. Analysis of secondary outcomes revealed a moderate effect for improvements in physical function, fatigue and psychological symptoms.

Conclusions

Aerobic and resistance exercises are tolerable and effective adjunct therapies to reduce cancer-related pain while also improving physical function, fatigue and mood. Future RCTs of dose, frequency, compliance and exercise type in specific cancer settings are required.

Posttraumatic growth in palliative care settings: A scoping review of prevalence, characteristics and interventions

BACKGROUND

Posttraumatic growth refers to positive psychological change following trauma. However, there is a need to better understand the experience of posttraumatic growth in the palliative care setting as well as the availability and efficacy of interventions that target this phenomenon.

AIMS

To provide a review of the prevalence, characteristics and interventions involving posttraumatic growth in adults receiving palliative care and to collate recommendations for future development and utilisation of interventions promoting posttraumatic growth.

DESIGN

We performed a systematic scoping review of studies investigating posttraumatic growth in palliative care settings using the Arksey and O'Malley six-step scoping review criteria. We used the PRISMA guidelines for scoping reviews.

DATA SOURCES

Articles in all languages available on Ovid Medline [1946-2022], Embase [1947-2022], APA PsycINFO [1947-2022] and CINAHL [1981-2022] in November 2022.

RESULTS

Of 2167 articles located, 17 were included for review. These reported that most people report low to moderate levels of posttraumatic growth with a decline towards end-of-life as distress and symptom burden increase. Associations include a relationship between posttraumatic growth, acceptance and greater quality-of-life. A limited number of interventions have been evaluated and found to foster posttraumatic growth and promote significant psychological growth.

CONCLUSION

Posttraumatic growth is an emerging concept in palliative care where although the number of studies is small, early indications suggest that interventions fostering posttraumatic growth may contribute to improvements in psychological wellbeing in people receiving palliative care.

Dying with behavioral and psychological symptoms of dementia in Australian nursing homes: a retrospective case-control study

Objectives

To identify predictors of mortality in people with active and challenging behavioral and psychological symptoms of dementia (BPSD).

Design

A retrospective case-control study was designed to compare those referred to Dementia Support Australia (DSA) who died in the 12 months to November 2016, with an equal number of controls who did not die. An audit tool was designed after literature review and expert opinion from the service. Odds ratio calculations and the Mann-Whitney U test were used to assess for difference.

Setting

Residents of Australian residential aged care facilities with BPSD referred to the DSA service.

Participants

Of 476 patients referred to DSA during the study period, 44 died. 44 controls were randomly selected from those remaining matched for age and sex.

Results

Significant differences included higher rates of benzodiazepine use, drowsiness, delirium, reduced oral intake and discussions about goals of care in those who died. Those who died were referred to the service for a shorter period and had more frequent contact between DSA and nurses at the nursing homes. Increase in opioid use and loss of skin integrity in those who died approached significance. The overall end of life course demonstrated a complex set of needs with frequent delirium, pain and frailty.

Conclusion

Further study is required to determine the optimal care for those with BPSD at the end of their lives. This study would indicate complex end of life care needs and point to a role for palliative care support.

Australian residential aged care home staff experiences of implementing an intervention to improve palliative and end-of-life care for residents: A qualitative study

Access to high-quality and safe evidence-based palliative care (PC) is important to ensure good end-of-life care for older people in residential aged care homes (RACHs). However, many barriers to providing PC in RACHs are frequently cited. The Quality End-of-Life Care (QEoLC) Project was a multicomponent intervention that included training, evidence-based tools and tele-mentoring, aiming to equip healthcare professionals and careworkers in RACHs with knowledge, skills and confidence in providing PC to residents. This study aims to understand: (1) the experiences of healthcare professionals, careworkers, care managers, planners/implementers who participated in the implementation of the QEoLC Project; and (2) the barriers and facilitators to the implementation. Staff from two RACHs in New South Wales, Australia were recruited between September to November 2021. Semi-structured interviews and thematic data analysis were used. Fifteen participants (seven health professionals [includes one nurse, two clinical educators, three workplace trainers, one clinical manager/nurse], three careworkers and five managers) were interviewed. Most RACH participants agreed that the QEoLC Project increased their awareness of PC and provided them with the skills/confidence to openly discuss death and dying. Participants perceived that the components of the QEoLC Project had the following benefits for residents: more appropriate use of medications, initiation of timely pain management and discussions with families regarding end-of-life care preferences. Key facilitators for implementation were the role of champions, the role of the steering committee, regular clinical meetings to discuss at-risk residents and mentoring. Implementation barriers included: high staff turnover, COVID-19 pandemic, time constraints, perceived absence of executive sponsorship, lack of practical support and systems-related barriers. The findings underline the need for strong leadership, supportive organisational culture and commitment to the implementation of processes for improving the quality of end-of-life care. Furthermore, the results highlight the need for codesigning the intervention with RACHs, provision of dedicated staff/resources to support implementation, and integration of project tools with existing systems for achieving effective implementation outcomes.

Effect of Cancer Pain Guideline Implementation on Pain Outcomes Among Adult Outpatients With Cancer-Related Pain: A Stepped Wedge Cluster Randomized Trial

IMPORTANCE

An evidence-practice gap exists for cancer pain management, and cancer pain remains prevalent and disabling.

OBJECTIVES

To evaluate the capacity of 3 cancer pain guideline implementation strategies to improve pain-related outcomes for patients attending oncology and palliative care outpatient services.

DESIGN, SETTING, AND PARTICIPANTS

A pragmatic, stepped wedge, cluster-randomized, nonblinded, clinical trial was conducted between 2014 and 2019. The clusters were cancer centers in Australia providing oncology and palliative care outpatient clinics. Participants included a consecutive cohort of adult outpatients with advanced cancer and a worst pain severity score of 2 or more out of 10 on a numeric rating scale (NRS). Data were collected between August 2015 and May 2019. Data were analyzed July to October 2019 and reanalyzed November to December 2021.

INTERVENTIONS

Guideline implementation strategies at the cluster, health professional, and patient levels introduced with the support of a clinical champion.

MAIN OUTCOMES AND MEASURES

The primary measure of effect was the percentage of participants initially screened as having moderate to severe worst pain (NRS ≥ 5) who experienced a clinically important improvement of 30% or more 1 week later. Secondary outcomes included mean average pain, patient empowerment, fidelity to the intervention, and quality of life and were measured in all participants with a pain score of 2 or more 10 at weeks 1, 2, and 4.

RESULTS

Of 8099 patients screened at 6 clusters, 1564 were eligible, and 359 were recruited during the control phase (mean [SD] age, 64.2 [12.1] years; 196 men [55%]) and 329 during the intervention phase (mean [SD] age, 63.6 [12.7] years; 155 men [47%]), with no significant differences between phases on baseline measures. The mean (SD) baseline worst pain scores were 5.0 (2.6) and 4.9 (2.6) for control and intervention phases, respectively. The mean (SD) baseline average pain scores were 3.5 (2.1) for both groups. For the primary outcome, the proportions of participants with a 30% or greater reduction in a pain score of 5 or more of 10 at baseline were similar in the control and intervention phases (31 of 280 participants [11.9%] vs 30 of 264 participants [11.8%]; OR, 1.12; 95% CI, 0.79-1.60; P = .51). No significant differences were found in secondary outcomes between phases. Fidelity to the intervention was low.

CONCLUSIONS AND RELEVANCE

A suite of implementation strategies was insufficient to improve pain-related outcomes for outpatients with cancer-related pain. Further evaluation is needed to determine the required clinical resources needed to enable wide-scale uptake of the fundamental elements of cancer pain care. Ongoing quality improvement activities should be supported to improve sustainability.

Feasibility and acceptability of virtual reality for cancer pain in people receiving palliative care: a randomised cross-over study

CONTEXT

Pain management in palliative care remains inadequate; the development of innovative therapeutic options is needed.

OBJECTIVES

To determine the feasibility and preliminary effectiveness for larger randomised controlled trials of 3D head-mounted (HMD) virtual reality (VR) for managing cancer pain (CP) in adults.

METHODS

Thirteen people receiving palliative care participated in a single-session randomised cross-over trial, after which they completed a qualitative semi-structured interview. We also compared the effects of 3D HMD VR and 2D screen applications on CP intensity and levels of perceived presence. Feasibility was assessed with recruitment, completion rates and time required to recruit target sample.

RESULTS

Although recruitment was slow, completion rate was high (93%). Participants reported that the intervention was acceptable and caused few side effects. Although participants reported significantly reduced CP intensity after 3D HMD VR (1.9 ± 1.8, P = .003) and 2D screen applications (1.5 ± 1.6, P = .007), no significant differences were found between interventions (-.38 ± 1.2, 95% CI: -1.1-.29, P = .23). Participants reported significantly higher levels of presence with the 3D HMD VR compared to 2D screen (60.7 ± SD 12.4 versus 34.3 ± SD 17.1, mean 95% CI: 16.4-40.7, P = .001). Increased presence was associated with significantly lower pain intensity (mean 95% CI: -.04--0.01, P = 0.02).

CONCLUSIONS

Our preliminary findings support growing evidence that both 3D and 2D virtual applications provide pain relief for people receiving palliative care. Given the relative lack of cybersickness and increasing access to portable VR, we suggest that larger clinical studies are warranted.

What is symptom meaning? A framework analysis of communication in palliative care consultations

OBJECTIVE

There is a limited understanding of symptom meaning and its significance to clinical practice within symptom experience literature. This study aims to qualitatively explore the ways in which symptom meanings are discussed by patients and responded to by palliative care physicians during consultations.

METHODS

Framework analysis was conducted with 40 palliative care consultation transcripts.

RESULTS

55% of consultations discussed symptom meaning. Six themes regarding patients' symptom meanings emerged while four themes conveyed physicians' responses to these utterances. Key symptom meanings included symptoms representing diminished function and uncertainty about symptom cause or future. Physicians usually gave scientific medical responses concerning symptom cause and treatment, versus reassurance or empathy.

CONCLUSION

This study has provided greater insight into the different symptom meanings that exist for palliative care patients. Physicians' responses highlight their reliance on medical information when patients are distressed. Future studies should explore the impact of different responses on patient outcomes, and health practitioners' views about optimal responses.

PRACTICE IMPLICATIONS

Physicians could explore symptom meanings with their patients, looking out for those identified here. Apart from information-giving and treatment, active listening to these concerns as they present in consultations may help improve the therapeutic relationship and better guide optimal care.

Clinicians' Perspectives on Managing Symptom Clusters in Advanced Cancer: A Semistructured Interview Study

CONTEXT

Managing symptom clusters or multiple concurrent symptoms in patients with advanced cancer remains a clinical challenge. The optimal processes constituting effective management of symptom clusters remain uncertain.

OBJECTIVES

To describe the attitudes and strategies of clinicians in managing multiple co-occurring symptoms in patients with advanced cancer.

METHODS

Semistructured interviews were conducted with 48 clinicians (palliative care physicians [n = 10], oncologists [n = 6], general practitioners [n = 6], nurses [n = 12], and allied health providers [n = 14]), purposively recruited from two acute hospitals, two palliative care centers, and four community general practices in Sydney, Australia. Transcripts were analyzed using thematic analysis and adapted grounded theory.

RESULTS

Six themes were identified: uncertainty in decision making (inadequacy of scientific evidence, relying on experiential knowledge, and pressure to optimize care); attunement to patient and family (sensitivity to multiple cues, prioritizing individual preferences, addressing psychosocial and physical interactions, and opening Pandora's box); deciphering cause to guide intervention (disaggregating symptoms and interactions, flexibility in assessment, and curtailing investigative intrusiveness); balancing complexities in medical management (trading off side effects, minimizing mismatched goals, and urgency in resolving severe symptoms); fostering hope and empowerment (allaying fear of the unknown, encouraging meaning making, championing patient empowerment, and truth telling); and depending on multidisciplinary expertise (maximizing knowledge exchange, sharing management responsibility, contending with hierarchical tensions, and isolation and discontinuity of care).

CONCLUSION

Management of symptom clusters, as both an art and a science, is currently fraught with uncertainty in decision making. Strengthening multidisciplinary collaboration, continuity of care, more pragmatic planning of clinical trials to address more than one symptom, and training in symptom cluster management are required.

Pharmacovigilance in hospice/palliative care: net effect of pregabalin for neuropathic pain

INTRODUCTION

Real-world effectiveness of many medications has been poorly researched, including in hospice/palliative care. Directly extrapolating findings from other clinical settings may not yield robust clinical advice. Pharmacovigilance studies provide an opportunity to understand better the net impact of medications. The study aimed to examine immediate and short-term benefits and harms of pregabalin in routine practice for neuropathic pain in hospice/palliative care.

METHODS

A consecutive cohort of 155 patients from 62 centres in 5 countries was started on pregabalin and studied prospectively. Data were collected at three time points: baseline; day 7 (immediate, short-term harms); ad hoc reports of any harms ≤21 days; and day 21 (short-term benefits).

RESULTS

Median dose for 155 patients at day 21 was 150 mg/24 h. Benefits were reported by 61 patients (39%), of whom 11 (7%) experienced complete pain resolution. Harms were reported by 51 (35%) patients at or before 7 days, the most frequent of which were somnolence, fatigue, cognitive disturbance and dizziness. 10 patients (6%) ceased pregabalin due to harms, but 82 patients (53%) were being treated at 21 days. In regression modelling, people with worse baseline pain derived more benefit (OR=8.5 (95% CI 2.5 to 28.68).

CONCLUSIONS

Pregabalin delivered benefit to many patients, with 4 of 10 experiencing pain reductions by 21 days. Harms, occurring in 1 in 3 patients, may be difficult to detect in clinical practice, as they mostly involve worsening of symptoms prevalent at baseline.

Symptom Clusters in Advanced Cancer Patients: An Empirical Comparison of Statistical Methods and the Impact on Quality of Life

CONTEXT

Symptom clusters in advanced cancer can influence patient outcomes. There is large heterogeneity in the methods used to identify symptom clusters.

OBJECTIVES

To investigate the consistency of symptom cluster composition in advanced cancer patients using different statistical methodologies for all patients across five primary cancer sites, and to examine which clusters predict functional status, a global assessment of health and global quality of life.

METHODS

Principal component analysis and exploratory factor analysis (with different rotation and factor selection methods) and hierarchical cluster analysis (with different linkage and similarity measures) were used on a data set of 1562 advanced cancer patients who completed the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire-Core 30.

RESULTS

Four clusters consistently formed for many of the methods and cancer sites: tense-worry-irritable-depressed (emotional cluster), fatigue-pain, nausea-vomiting, and concentration-memory (cognitive cluster). The emotional cluster was a stronger predictor of overall quality of life than the other clusters. Fatigue-pain was a stronger predictor of overall health than the other clusters. The cognitive cluster and fatigue-pain predicted physical functioning, role functioning, and social functioning.

CONCLUSIONS

The four identified symptom clusters were consistent across statistical methods and cancer types, although there were some noteworthy differences. Statistical derivation of symptom clusters is in need of greater methodological guidance. A psychosocial pathway in the management of symptom clusters may improve quality of life. Biological mechanisms underpinning symptom clusters need to be delineated by future research. A framework for evidence-based screening, assessment, treatment, and follow-up of symptom clusters in advanced cancer is essential.

Pharmacovigilance in hospice/palliative care: net effect of gabapentin for neuropathic pain

OBJECTIVE

Hospice/palliative care patients may differ from better studied populations, and data from other populations cannot necessarily be extrapolated into hospice/palliative care clinical practice. Pharmacovigilance studies provide opportunities to understand the harms and benefits of medications in routine practice. Gabapentin, a γ-amino butyric acid analogue antiepileptic drug, is commonly prescribed for neuropathic pain in hospice/palliative care. Most of the evidence however relates to non-malignant, chronic pain syndromes (diabetic neuropathy, postherpetic neuralgia, central pain syndromes, fibromyalgia). The aim of this study was to quantify the immediate and short-term clinical benefits and harms of gabapentin in routine hospice/palliative care practice.

DESIGN

Multisite, prospective, consecutive cohort.

POPULATION

127 patients, 114 of whom had cancer, who started gabapentin for neuropathic pain as part of routine clinical care.

SETTINGS

42 centres from seven countries. Data were collected at three time points-at baseline, at day 7 (and at any time; immediate and short-term harms) and at day 21 (clinical benefits).

RESULTS

At day 21, the average dose of gabapentin for those still using it (n=68) was 653 mg/24 h (range 0-1800 mg) and 54 (42%) reported benefits, of whom 7 (6%) experienced complete pain resolution. Harms were reported in 39/127 (30%) patients at day 7, the most frequent of which were cognitive disturbance, somnolence, nausea and dizziness. Ten patients had their medication ceased due to harms. The presence of significant comorbidities, higher dose and increasing age increased the likelihood of harm.

CONCLUSIONS

Overall, 42% of people experienced benefit at a level that resulted in continued use at 21 days.

The Population Burden of Chronic Symptoms that Substantially Predate the Diagnosis of a Life-Limiting Illness

Many people in our communities live with symptoms for years or decades, something of relevance to hospice/palliative care clinicians and researchers. The proportion of people in the community at large who have a chronic symptom is likely to approximate the proportion of people referred to hospice/palliative care services with that same chronic symptom that pre-dates their life-limiting illness. Such patients may have different responsiveness to, and expectations from, symptomatic therapies, thus requiring more advanced approaches to symptom control. For researchers evaluating the impact of hospice/palliative care services, failing to account for people with long-term refractory symptoms pre-dating their life-limiting illness may systematically underestimate services' benefits. Observational symptom prevalence studies reported in hospice/palliative care to date have not accounted for people with long-term refractory symptoms, potentially systematically overestimating symptoms attributed to life-limiting illnesses. Cross-sectional community prevalence rates of key chronic refractory symptoms largely unrelated to their life-limiting illness reflect the likely prevalence on referral to hospice/palliative care: fatigue (up to 35%); pain (12%-31%); pain with neuropathic characteristics (9%); constipation (2%-29%); dyspnea (4%-9%); cognitive impairment (>10% of people >65 years old; >30% of people >85 years old); anxiety (4%); and depression (lifetime incidence 2%-15%; one year prevalence 3%). Prospective research is needed to establish (1) the prevalence and severity of chronic symptoms that pre-date the diagnosis of a life-limiting illness in people referred to hospice/palliative care services, comparing this to whole-of-population estimates; and (2) whether this group is disproportionately represented in people with refractory symptoms.

Symptom clusters in patients with advanced cancer: a systematic review of observational studies

CONTEXT

Advanced cancer patients typically experience multiple symptoms, which may influence patient outcomes synergistically. The composition of these symptom clusters (SCs) differs depending on various clinical variables and the timing and method of their assessment.

OBJECTIVES

The objective of this systematic review was to examine the composition, longitudinal stability, and consistency across methodologies of common SCs, as well as their common predictors and outcomes.

METHODS

A search of MEDLINE, CINAHL, Embase, Web of Science, and PsycINFO was conducted using variants of symptom clusters, cancer, and palliative care.

RESULTS

Thirty-three articles were identified and reviewed. Many SCs were identified, with four common groupings being anxiety-depression, nausea-vomiting, nausea-appetite loss, and fatigue-dyspnea-drowsiness-pain. SCs in most cases were not stable longitudinally. The various statistical methods used (most commonly principal component analysis, exploratory factor analysis, and hierarchical cluster analysis) tended to reveal different SCs. Different measurement tools were used in different studies, each containing a different array of symptoms. The predictors and outcomes of SCs were also inconsistent across studies. No studies of patient experiences of SCs were identified.

CONCLUSION

Although the articles reviewed revealed four groups of symptoms that tended to cluster, there is limited consistency in the way in which SCs and variables associated with them are identified. This is largely due to a lack of agreement about a robust, clinically relevant definition of SCs. Future research should focus on patients' subjective experience of SCs to inform a clinically relevant definition of SCs and how they are managed over time.

Patient Education, Coaching, and Self-Management for Cancer Pain

Purpose

Multiple systematic reviews and meta-analyses have identified the effectiveness of patient education in improving cancer pain management. However, the mechanisms by which patient education improves pain outcomes are uncertain, as are the optimal delivery, content, timing, frequency, and duration. This review provides best-bet recommendations based on available evidence to guide service managers and clinicians in developing a patient education program.

Methods

We used patient-centered care, self-management, coaching, and a behavior change wheel as lenses through which to consider the evidence for elements of patient education most likely to be effective within the context of other strategies for overcoming barriers to cancer pain assessment and management.

Results

The evidence suggests that optimal strategies include those that are patient-centered and tailored to individual needs, are embedded within health professional–patient communication and therapeutic relationships, empower patients to self-manage and coordinate their care, and are routinely integrated into standard cancer care. An approach that integrates patient education with processes and systems to ensure implementation of key standards for pain assessment and management and education of health professionals has been shown to be most effective.

Conclusion

Patient education is effective in reducing cancer pain and should be standard practice in all settings. For optimal results, patient education should be integrated with other strategies for implementing evidence-based, person-centered care and overcoming barriers at the levels of patient, provider, and health system.

A randomized controlled trial of a standardized educational intervention for patients with cancer pain

CONTEXT

Published literature has not defined the effectiveness of standardized educational tools that can be self-administered in the general oncology population with pain.

OBJECTIVES

We sought to determine if an educational intervention consisting of a video and/or booklet for adults with cancer pain could improve knowledge and attitudes about cancer pain management, pain levels, pain interference, anxiety, quality of life, and analgesic use.

METHODS

Eligible participants had advanced cancer, a pain score >/=2 of 10 in the last week, English proficiency, an estimated prognosis of more than one month, and were receiving outpatient cancer treatment at participating hospitals. Participants completed baseline assessments and then were randomly allocated to receive a booklet, a video, both, or neither, in addition to standard care. Outcome measures at two and four weeks included the Barriers Questionnaire (BQ), Brief Pain Inventory, Global Quality of Life Scale, and Hospital Anxiety and Depression Scale. Adequacy of analgesia and severity of pain were assessed with the Pain Management Index and a daily pain diary.

RESULTS

One hundred fifty-eight participants were recruited from 21 sites over 42 months. Baseline mean barriers scores were lower than reported in previous Australian studies at 1.33 (standard deviation: 0.92). Mean average pain and worst pain scores improved significantly in patients receiving both the video and booklet by 1.17 (standard error [SE]: 0.51, P=0.02) and 1.12 (SE: 0.57, P=0.05), respectively, on a 0-10 scale. The addiction subscale of the BQ score was improved by 0.44 (SE: 0.19) for participants receiving any part of the intervention (P=0.03).

CONCLUSION

Provision of a video and/or booklet for people with cancer pain was a feasible and effective adjunct to the management of cancer pain.

[The undetected brain lesion in sports. Minor traumatic brain injury and its sequelae]

The minor traumatic brain injury (mTBI) in sports is often looked at as a bagatelle. The treating physician underestimates the severity of the injury suspecting that a mTBI is a nonstructural lesion with an overall excellent prognosis in the majority of the cases. This paper shows that the minor traumatic brain injury may be a structural brain lesion with potentially life-threatening dangers. The therapy should follow exactly defined guidelines, e.g., stepwise protocol of the Concussion in Sports (CIS-) Group. Return to sports activities should happen only when all physical but also cognitive symptoms have subsided. All mTBIs that have been sustained prior to the actual injury have to be recorded properly because repeated mTBIs may cause chronic degenerative brain damage. Neuropsychological testing will aid in the correct diagnosis of a mTBI and is a useful parameter in the course of the injury. In the future biochemical markers may serve as indicators of the severity of the brain injury and may also aid in predicting the outcome after TBI. Today biochemical markers do not serve as a substitute for neuroimaging.

No cumulative effects for one or two previous concussions

BACKGROUND

Sports medicine clinicians and the general public are interested in the possible cumulative effects of concussion.

OBJECTIVE

To examine whether athletes with a history of one or two previous concussions differed in their preseason neuropsychological test performances or symptom reporting.

METHOD

Participants were 867 male high school and university amateur athletes who completed preseason testing with ImPACT version 2.0. They were sorted into three groups on the basis of number of previous concussions. There were 664 athletes with no previous concussions, 149 with one previous concussion, and 54 with two previous concussions. Multivariate analysis of variance was conducted using the verbal memory, visual memory, reaction time, processing speed, and postconcussion symptom composite scores as dependent variables and group membership as the independent variable.

RESULTS

There was no significant multivariate effect, nor were there any significant main effects for individual scores. There was no measurable effect of one or two previous concussions on athletes' preseason neuropsychological test performance or symptom reporting.

CONCLUSION

If there is a cumulative effect of one or two previous concussions, it is very small and undetectable using this methodology.

The assessment of sport-related concussion: the evidence behind neuropsychological testing and management

Because of the lack of valid evidence to support the current recommendations for the management of mild traumatic brain injury (concussion), many physicians, athletic trainers, coaches, and athletes have called into question the way concussions are treated in athletics. This review article discusses the current evidence for the management of concussion in high school, college, and professional sports. A complete review of the epidemiologic and neuropsychological studies to date is presented and critically reviewed, as are other assessment and management tools in concussion. The appropriate use of neuropsychological testing, grading scales, and return-to-play recommendations are discussed in depth based on the current evidence. Additionally, areas requiring further research are identified and future trends are briefly discussed.

Prevalence of abnormal CT-scans following mild head injury

PRIMARY OBJECTIVE

The purpose of this study was to examine the prevalence of day-of-injury intracranial abnormalities in a large sample of patients with mild head injuries who were admitted to a Trauma Service.

METHODS AND PROCEDURES

There were 912 patients who obtained admission Glasgow Coma Scale (GCS) scores of 13-15.

MAIN OUTCOMES AND RESULTS

The base rate of complicated mild head injuries (i.e. abnormal CT scans) in this sample was 15.8%. However, nearly 25% of the sample, most of whom had very mild injuries, did not receive CT-scans. Therefore, the actual prevalence is more likely in the range 16-21%. There was a tremendous overlap in injury characteristics between patients with complicated and uncomplicated mild head injuries. None the less, there were modest, yet statistically significant, relationships between the presence of intracranial abnormalities and lower GCS scores, greater frequency of positive loss of consciousness, greater frequency of skull fractures, and lower GOAT scores.

Does brief loss of consciousness affect cognitive functioning after mild head injury?

Loss of consciousness often is considered an important variable when estimating head injury severity. The purpose of this study was to determine if brief loss of consciousness had any effect on the neuropsychological test performance of patients in acute recovery from an uncomplicated mild head injury (N = 195). Three groups of 65 patients were given a brief battery of neuropsychological tests within one week of sustaining a mild head injury. The groups, sorted on the basis of loss of consciousness (i.e., positive, negative, or equivocal), did not differ in age or education. There were no significant differences among the groups on any of the measures of attention, learning, memory, language, or executive functioning.

The use of herbal alternative medicines in neuropsychiatry. A report of the ANPA Committee on Research

Growing numbers of people throughout the United States (40% in 1998) are using various forms of alternative therapies. A MEDLINE literature search of journals from the past three decades and an Internet database query were performed to determine the types and frequency of alternative therapies used, with special attention given to the herbal medicines used in neuropsychiatric disorders. Clinical effects, mechanisms of action, interactions, and adverse reactions of the herbal treatments are detailed. Objective controlled trials will be needed to establish safety and efficacy of herbal supplements. Knowledge of the properties of these therapies can improve the care of neuropsychiatric patients.

Cerebral concussion in athletes: evaluation and neuropsychological testing

OBJECTIVE

To conduct a topic review of studies related to cerebral concussion in athletes, as an aid to improving decision-making and outcomes.

METHODS

We review the literature to provide an historical perspective on the incidence and definition of and the management guidelines for mild traumatic brain injury in sports. In addition, metabolic changes resulting from cerebral concussion and the second-impact syndrome are reviewed, to provide additional principles for decision-making. Neuropsychological testing, as it applies to athletes, is discussed in detail, to delineate baseline assessments, the characteristics of the neuropsychological evaluation, the neuropsychological tests used, and the methods for in-season identification of cerebral concussion. Future directions in the management of concussions are presented.

RESULTS

The incidence of cerebral concussions has been reduced from approximately 19 per 100 participants in football per season to approximately 4 per 100, i.e., 40,000 to 50,000 concussions per year in football alone. The most commonly used definitions of concussion are those proposed by Cantu and the American Academy of Neurology. Each has associated management guidelines. Concussion or loss of consciousness occurs when the extracellular potassium concentration increases beyond the upper normal limit of approximately 4 to 5 mmol/L, to levels of 20 to 50 mmol/L, inhibiting the action potential and leading to loss of consciousness. This phenomenon helps to explain the delayed effects of symptoms after trauma.

CONCLUSION

Neuropsychological testing seems to be an effective way to obtain useful data on the short-term and long-term effects of mild traumatic brain injury. Moreover, knowledge of the various definitions and management strategies, as well as the utility of neuropsychological testing, is essential for those involved in decision-making with athletes with mild traumatic brain injuries.

Normative comparisons for the controlled oral word association test following acute traumatic brain injury

The Controlled Oral Word Association Test (COWAT) is widely used in clinical neuropsychology as a measure of verbal fluency. It is important for psychologists to realize that using the recently published normative data will result in different clinical conclusions because the updated normative sample performed better than the original normative sample. The purpose of this study was to compare the original and updated norms in a large sample of patients with acute traumatic brain injuries (N=669). The percentages of patients who scored below the 5th centile in each system varied as a function of brain injury severity. Moreover, a substantially larger number of patients scored in the impaired range according to the updated normative data.

Does loss of consciousness predict neuropsychological decrements after concussion?

OBJECTIVE

To investigate the importance of loss of consciousness (LOC) in predicting neuropsychological test performance in a large sample of patients with head injury.

DESIGN

Retrospective comparison of neuropsychological test results for patients who suffered traumatic LOC, no LOC, or uncertain LOC.

SETTING

Allegheny General Hospital, Pittsburgh, Pennsylvania.

PATIENTS

The total number of patients included in this study was 383.

MAIN OUTCOME MEASURES

Neuropsychological test measures, including the visual reproduction, digit span, and logical memory subtests of the Wechsler memory scale (revised), the Trail Making test, Wisconsin Card Sorting test, Hopkins Verbal Learning test, Controlled Oral Word Association, and the Galveston Orientation and Amnesia test (GOAT).

RESULTS

No significant differences were found between the LOC, no LOC, or uncertain LOC groups for any of the neuropsychological measures used. Patients who had experienced traumatic LOC did not perform more poorly on neuropsychological testing than those with no LOC or uncertain LOC. All three groups demonstrated mildly decreased performance on formal tests of speed of information processing, attentional process, and memory.

CONCLUSION

The results of this study cast doubt on the importance of LOC as a predictor of neuropsychological test performance during the acute phase of recovery from mild traumatic brain injury. Neuropsychological testing procedures have been shown to be sensitive in measuring cognitive sequelae of mild traumatic brain injury (concussion) in athletes. The failure of this study to find any relationship between LOC and neuropsychological functioning in a large sample of patients with mild head trauma calls into question the assignment of primary importance to LOC in grading severity of concussion. This study also does not provide support for the use of guidelines that rely heavily on LOC in making return-to-play decisions. Continued research is necessary to determine the relative importance of markers of concussion in athletes.

Relationship between concussion and neuropsychological performance in college football players

CONTEXT

Despite the high prevalence and potentially serious outcomes associated with concussion in athletes, there is little systematic research examining risk factors and short- and long-term outcomes.

OBJECTIVES

To assess the relationship between concussion history and learning disability (LD) and the association of these variables with neuropsychological performance and to evaluate postconcussion recovery in a sample of college football players.

DESIGN, SETTING, AND PARTICIPANTS

A total of 393 athletes from 4 university football programs across the United States received preseason baseline evaluations between May 1997 and February 1999. Subjects who had subsequent football-related acute concussions (n = 16) underwent neuropsychological comparison with matched control athletes from within the sample (n = 10).

MAIN OUTCOME MEASURES

Clinical interview, 8 neuropsychological measures, and concussion symptom scale ratings at baseline and after concussion.

RESULTS

Of the 393 players, 129 (34%) had experienced 1 previous concussion and 79 (20%) had experienced 2 or more concussions. Multivariate analysis of variance yielded significant main effects for both LD (P<.001) and concussion history (P=.009), resulting in lowered baseline neuropsychological performance. A significant interaction was found between LD and history of multiple concussions and LD on 2 neuropsychological measures (Trail-Making Test, Form B [P=.007] and Symbol Digit Modalities Test [P=.009]), indicating poorer performance for the group with LD and multiple concussions compared with other groups. A discriminant function analysis using neuropsychological testing of athletes 24 hours after acute in-season concussion compared with controls resulted in an overall 89.5% correct classification rate.

CONCLUSIONS

Our study suggests that neuropsychological assessment is a useful indicator of cognitive functioning in athletes and that both history of multiple concussions and LD are associated with reduced cognitive performance. These variables may be detrimentally synergistic and should receive further study.

Neuropsychological assessment of the college football player

The application of neuropsychological assessment procedures to the evaluation of athletes has recently become an area of intense interest and debate and has led to the development of research initiatives at both the amateur and the professional level. However, to date, only a handful of research studies have been completed that have addressed the special issues that accompany the use of neuropsychological assessment instruments with athletes. This article reviews the past use of psychological testing in sports and presents a model of neuropsychological assessment that is currently being utilized in the National Football League. In addition, the extension of this approach to major college football is discussed and test-retest data from a sample presented to provide the basis for comparison of athletes who have suffered a concussion. Recommendations of a national panel of neuropsychologists who are involved in the evaluation of athletes are presented in hopes of encouraging new research initiatives in this area.

Neuropsychological function in restrained versus unrestrained motor vehicle occupants who suffer closed head injury

It is known that using seatbelts reduces the incidence and severity of closed head injury (CHI) from motor vehicle crashes. One would expect unrestrained occupants in motor vehicle crashes to suffer more severe CHIs than restrained occupants, as reflected by Glasgow Coma Scale (GCS) scores. One might also expect an increased risk of focal injury due to contact forces in unrestrained occupants. The purpose of this study was to test the hypothesis that failure to use seatbelts results in increased severity of neuropsychological sequelae, even with GCS controlled. We also examined the impact of demographic variables on seatbelt use. Subjects included patients admitted to a hospital trauma service who were suspected of having suffered CHI. All patients completed neuropsychological testing, which was entered into a data base along with demographic and clinical information. People who had documented use of seatbelt restraints were compared with those who were unrestrained. Results confirmed that certain demographic variables are associated with the use of seatbelts. Results also suggested that failure to use seatbelt restraints is associated with more severe impairment on tests that are sensitive to frontal lobe dysfunction.

Impact of skull fracture on neuropsychological functioning following closed head injury

The role of skull fracture in affecting morbidity following closed head injury (CHI) has received a significant amount of attention from researchers. While there is fairly widespread agreement that skull fractures increase the risk of complications such as haematoma, it us unclear whether the presence of skull fracture has predictive value in terms of the neuropsychological sequelae of CHI. The purpose of the current study was to further investigate the role of skull fracture in predicting neuropsychological dysfunction following CHI. Subjects included patients admitted to the trauma service of a large teaching hospital who were suspected of having suffered CHI. All patients completed neuropsychological testing and had normal computerized tomography (CT) scans. Patients who had suffered skull fracture were compared to those who had not suffered skull fracture on selected neuropsychological measures. Groups did not differ in terms of CHI severity as assessed by the Glasgow Coma Scale (GCS). Multivariate analysis of variance revealed that the groups did differ in terms of neuropsychological functioning. Results are interpreted as suggesting that the presence of a skull fracture is predictive of additional neuropsychological dysfunction, even in the absence of intracranial pathology or more severe disturbance of consciousness on the GCS.

Cognitive dysfunction after closed head injury: contributions of demographic, injury severity and other factors

Previous studies have identified a number of variables which help to predict cognitive dysfunction following closed head injury (CHI) The purpose of the current study was to evaluate the predictive utility of a number of risk factors in a large sample of trauma patients who suffered CHI and underwent neuropsychological assessment Risk factors included demographic variables, Glasgow coma scale (GCS), CT scan, loss of consciousness (LOC), and blood alcohol level (BAL) Multiple regression was used to assess the role of these variables in predicting cognitive dysfunction Results suggested that LOC did not predict cognitive dysfunction Demographic factors did emerge as predictors of cognitive dysfunction BAL was correlated with initial GCS, but did not predict cognitive dysfunction once post-traumatic amnesia cleared.

Increased middle cerebral artery flow velocity during the initial phase of cardiopulmonary bypass may cause neurological dysfunction

One hundred twenty-seven patients undergoing coronary artery bypass graft surgery were monitored by transcranial Doppler ultrasonography. Five patients had more than 50% increases in middle cerebral artery mean flow velocity during the initial phase (10-120 sec) of cardiopulmonary bypass. Four of these 5 developed neurological complications including stroke and encephalopathy. These results indicate that overperfusion of the basal cerebral arteries during cardiopulmonary bypass procedures may contribute to neurological dysfunction after the surgery.

Microemboli during coronary artery bypass grafting. Genesis and effect on outcome

Cerebral dysfunction after coronary artery bypass operations represents some of the most serious and costly complications of cardiac surgery. We used transcranial Doppler ultrasonography to detect and quantify the number of microemboli in the right middle cerebral artery of patients undergoing elective first coronary bypass operations (n = 117) and second coronary bypass operations (n = 10). We hypothesized that total microemboli were related to clinical outcome. A 2 MHz transducer was positioned in front of the ear above the zygomatic arch and depth gated to 50 mm. Microemboli were recorded as perturbations of the blood flow velocity in the middle cerebral artery and aurally monitored. Each episode of microembolism was specified both by clock time and as a perfusion or surgical event. Forty-one patients (32%) completed neuropsychologic evaluation with a battery of tests for cognitive function. Anxiety states and traits were also assessed. The distribution of microembolism showed that there were three groups of patients: < 30 microemboli (n = 83); 30 to 59 (n = 24); and > 60 (n = 20). Seven of 10 patients with cerebral complications (stroke, coma, delirium, aberrant behavior) were in the > 60 microemboli group. Those with cerebral complications had 20.7 +/- 4.5 microemboli from perfusion and 57.4 +/- 15.6 from surgical events. The 13 patients in the > 60 microemboli group without central nervous system symptoms had 95.5 +/- 19.5 microemboli from perfusion and 36.0 +/- 6.9 from surgical events. Neuropsychologic scores were most often depressed for memory (73%), comprehension (49%), attention (46%), and constructional ability (44%). The greatest change was in total score in the > 60 microemboli group (-3.3 +/- 0.6) compared with -1.1 +/- 0.2 and -1.9 +/- 0.2 for the 30 to 59 and < 30 groups, respectively. The incidences of cardiac and pulmonary complications and mortality were different between those patients with < 60 microemboli versus those with > 60 microemboli. Cardiac and pulmonary complications and mortality percentages were 4.7%, 3.7%, and 0.9%, respectively, for the < 60 microemboli group and 20%, 20%, and 15%, respectively, for the > 60 microemboli group. We concluded that transcranial Doppler ultrasonography is a useful technique to quantify and detect the source of microemboli during coronary artery bypass operations and may be useful in assessing new operative strategies, the quality of the perfusion, and potentially as an indicator for pharmacologic therapy in the operating room in patients with high microemboli counts.

Assessment of treatment outcomes in neuropsychiatry: a report from the Committee on Research of the American Neuropsychiatric Association

The ANPA Committee on Research conducted a survey of its members and those of the British Neuropsychiatry Association to determine the extent to which neuropsychiatrists employ formal measures of clinical outcome. Results revealed that although respondents endorsed the practice of outcome assessment, formal diagnostic evaluations and outcome measures were rarely applied consistently to the broad range of neuropsychiatric conditions encountered clinically. These findings have implications for clinical research and managed care in neuropsychiatry and will form the basis for future work by the Committee on Research.

Effects of age of onset of partial and generalized seizures on neuropsychological performance in children

Neuropsychological performance data from 106 children with epilepsy were evaluated to determine the effects of seizure type and age of onset. The performance of children with partial seizures (N = 49) was similar to that of children with generalized seizures (N = 57). Only one of 13 tests showed a significant difference between groups, with children with partial seizures performing better on that test. The effects of age of onset were also similar in the two seizure groups. Children whose seizures began before the age of 5 years performed significantly worse than children whose seizures began later on four measures (Verbal IQ, Performance IQ, Trails A, and Trails B) and performed more poorly, but not significantly so, on the other nine measures in the battery. A breakdown of the partial group into simple partial, complex partial, and secondarily generalized partial seizure groups found a significant difference between the groups on only one variable, but there were suggestions in the data that the performance of the partial secondarily generalized group was worse than the other two groups. These results indicate that variables associated with an early onset of seizures, regardless of type, place a child at risk for cognitive dysfunction.

The effect of disodium 5-ribonucleotide on reproductive function over three generations in the rat

Deitary levels of 0.1, 1.0 and 2.0% disodium 5-ribonucleotide were administered to rats of the CD strain over 3 generations, and the growth and reproductive performance were compared with those of a control group. Treatment did not appear to affect parent animals, as assessed by the incidence of mortality, bodyweight change, food consumption, mating performance, Pregnancy rate, Gestation Peroid, and post-mortem findings. Total litter loss, Litter size, Litter and mean pup weights, pup mortality and the incidence of skeletal or other variants in the offspring were unaffected by treatment at any dosage level. Additional organ weight analysis and skeletal staining of 10 males and 10 females from all groups, and the histological examination of 10 male and 10 females of the control and 2.0% level groups of the third generation did not provide any evidence of effects that could be related to treatment.