connecting you to the research - brain injury...

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Spring 2011, Issue 14

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When Seniors Get Brain Injuries

Seniors Prevention Strategies

FES-Assisted Exercise

Guidelines for mTBI

Good Night?

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IN THIS ISSUEIN THIS ISSUE

Connecting YOU to the Research

When Seniors Get Brain Injuries

Canadians are staying healthier and living longer than everbefore. A century ago, one in 20 Canadians was a senior. Today, it’s closer to one in seven with the number of seniors in the country set to double to ten million over the next 25 years.

Seniors today tend to be fit andactive. It’s not unusual to find people in their 70s or even their 80splaying tennis, riding a bicycle, orstretching in a fitness class at thelocal recreation centre.

The Ontario NeurotraumaFoundation (ONF) is continuing toinvestigate the impact of braininjury on seniors. In addition to afocus on prevention strategiesaimed at reducing falls amongseniors (please see page 2), ONF isinterested in identifying researchareas of particular relevance forpeople who sustain a brain injurylate in life. To assess where ONFcan have some impact, both a literature review and an analysis ofOntario hospital data and commu-nity services have been

commissioned. Some initial areasof interest and information arehighlighted in this article. The ONF-funded studies will help theFoundation pinpoint the researchareas and approaches most likelyto improve outcomes for peoplewho sustain an acquired braininjury (ABI) late in life.

What sort of brain injuries are mostprevalent among people over 65?Both traumatic and non-traumaticbrain injuries affect seniors.According to preliminary results ofthe Ontario ABI Dataset, youngerseniors are five times more likely tobe hospitalized for a non-traumatic brain injury than for atraumatic brain injury. Amongolder seniors age 85 and up,

hospitalizations are more evenlydistributed for traumatic and non-traumatic brain injuries. The OntarioABI Dataset analysis is led byAngela Colantonio, SeniorResearch Scientist at TorontoRehab and Professor at theDepartment of OccupationalScience and OccupationalTherapy at the University ofToronto.

In recent years, falls have over-taken motor vehicle collisions asthe biggest cause of traumaticbrain injury for the senior population. “With older seniors wesee falls in the home and out in thecommunity,” said Shawn Marshall,Associate Professor in theDepartment of Medicine at theUniversity of Ottawa and clinicalinvestigator at the Ottawa HospitalResearch Institute.

Marshall indicated that injury

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http://www.onf.org

NeuroMatters Spring 2011, Issue 14

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patterns might be poised tochange because today’s seniorsare far more active than the previous generation was. The factthat today people 65 and olderenjoy skiing or riding motorcyclesmight lead to an eventual increasein traumatic brain injury amongyounger seniors.

But at present, falls are the number one cause of traumaticbrain injuries and it is the older senior who is most susceptible dueto age-related issues like poor balance, side effects of medications, and weakeningvision. A number of strategies existto address the prevention of seniors’ falls by minimizing risks.(Please see Prevention Strategies.)

The older brain is more vulnerable to disease and illness,and this means that non-traumaticbrain injuries like brain tumours,vascular insults and other diseasesof the brain account for a significant number of acquiredbrain injuries in older people.Colantonio’s analysis of theOntario ABI Dataset has shownthat brain tumours are more of aconcern in the younger elderly,while vascular insults tend to bemore common among the olderelderly.

DiagnosisBoth traumatic and non-traumaticABI can be difficult to diagnose atany age. Assessments involvingbrain injuries can be even morecomplicated in the senior population. Cognitive problems inlate onset brain injury can sometimes be confused withdementia or Alzheimer’s diseasewhen the patient is elderly. Eventhough the symptoms might besimilar, it is crucial to get a diagnosis right because the treatments and expectations forrecovery are very different.

In the case of a traumaticevent, a brain injury can be overlooked when another more

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In addition to its focus on the careand treatment of seniors once anacquired brain injury (ABI) hashappened, the OntarioNeurotrauma Foundation (ONF)also has a strong interest in prevention. Since falls are the mostcommon cause of traumatic braininjury in people over 75, ONF hasfocused on fall prevention strategies. In the past, ONF supported the “Stay on Your Feet”best practice intervention in threeOntario communities, and workedwith other groups and regions inthe province to learn from the successes of these communities.

More recently, ONF has becomeinvolved with two new initiatives.

Led by Ontario’s Local HealthIntegration Networks (LHINs) inpartnership with public health, andinvolving organizations such asONF, the Provincial Falls Prevention

Project was established last yearas a priority project for LHINs. Thegoal of the project is to improvethe quality of life and well-being ofseniors through prevention of fallsand fall-related injuries. An“Ontario Falls PreventionFramework and Toolkit” will bedeveloped, along with a plan tosupport the LHINs and publichealth units in implementing thetoolkit, monitoring implementationprogress and evaluating prevention interventions.

ONF is also the sponsoringagency for the Falls PreventionCommunity of Practice under theSeniors Health Research TransferNetwork funded by the Ministry ofHealth and Long Term Care. ThisNetwork links caregivers,researchers and policy-makers inan effort to improve the healthand healthcare for Ontario seniors.

Seniors Prevention Strategies


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to bounce back from an injury.“People who have a brain injurywhen they are older typically have a worse outcome than a youngerperson. A moderate injury canresult in a severe outcome if you’reover age 60,” said Marshall.

Rehabilitation and seniors with late onset ABIIndications are that changes areneeded throughout the healthcare system to better accommodate seniors. Criteria foreligibility for rehabilitation mayneed to be revised in the face ofincreasing numbers of seniors withABIs requiring care. Expectationsabout the length of rehabilitationand the definition of a successfuloutcome may also need adjusting.

“Rehabilitation is typicallydesigned to get young peopleback to work. Many rehabilitationprograms are not designed forolder people,” Marshall said. “Wehave to change our strategy withhow to deal with seniors with braininjuries. We might need todecrease the intensity of a rehabilitation program and re-alignthe goals.”

Marshall said that the benefits ofrehabilitation depend upon thecondition and fitness level a senioris in before the injury. A senior whois still driving and goes to the gymmight be considered a better candidate for rehabilitation than a

senior who was in a long-term carefacility before sustaining the ABI.ONF considers this area one of particular importance given thepredicted growth of the seniorpopulation.

Literature ReviewThe ONF-funded team working onthe collection of evidence-basedresearch in the rehabilitation fieldfor people with ABI (ERABI) hasbeen asked by ONF to provide amore in-depth review of the litera-ture on late onset ABI.

Data AnalysisONF has also commissioned amore in-depth analysis on ABI andseniors from the existing ABIDataset project. “We aim to showthe trajectory of older adults in thehealth care system from emer-gency room visits and hospitaliza-tion to post-acute care includinginpatient rehabilitation and com-munity services,” Colantonio said.

Systems IssuesWith the concerted focus of thehealth system on care and servicesfor seniors, ONF anticipates theresults of these two studies will helpbetter identify what can be donewithin the health system to improveefficiencies and patient outcomes.ONF will be looking to partner withother stakeholders to see where itcan have the best impact.

The Ontario Neurotrauma Foundation is committed to keeping you informed about

the research it supports in the areas of spinal cord injury and brain injury.

Go To: www.onf.organd click on “subscription”

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obvious or pressing injury is present,especially when medical personnel are not familiar with anolder patient’s pre-injury level ofcompetence.

ONF hopes to identify fertileareas of research in the area ofdiagnosis to help clinicians accurately identify ABI in seniors.

Dementia and TBIThe relationship between dementia and TBI is another areaof interest for ONF. There is someindication that TBI can lead todementia. Boxer’s dementia, forexample, is believed to be theresult of repeated TBIs, howevermild. But another view is that TBIdoes not cause dementia butrather speeds up the developmentof dementia by destroying neurons.

Pre-injury health profileThe health status of seniors beforean injury has a direct bearing ontheir outcome. This factor is exaggerated in the case of a senior with an ABI because olderpeople are more likely to haveone or more age-related conditions at the time of ABI onset.The effect of these conditions andtheir treatment on outcomes isanother topic that interests ONF.

Even when no other health conditions are present pre-injury,older bodies generally take longer

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Functional Electrical Stimulation-Assisted Exercise:Assessing the health benefits in individuals with a spinal cord injury

Functional Electrical Stimulation(FES) technology involves computer-generated patterns ofsmall electrical pulses that stimulate paralysed muscles to produce movements. Thesemovements may be limited to onelimb, as in the muscles used forgrasping, or they may involvewhole body actions such as bicycling. Many studies haveshown that FES-assisted activitiesmay assist useful, intentionalmovements and others have shown that FES- assisted exercise, such asbicycling, may have somehealth benefits. Many ofthese studies, however,involved case reports or just a few study participants.

The Ontario NeurotraumaFoundation (ONF) recentlyfunded a larger scalestudy into the effects of FES-assisted exercise on cardiovascular function and immune system properties. ONF wanted todiscover whether this form of exercise might help limit secondary health complications inindividuals with a spinal cord injury.

A team of researchers at theUniversity of Western Ontario examined the effects of a 12 weekprogram of FES-assisted bicycling inpeople with chronic (longer than12 months) paraplegia or tetraplegia. Each participant wasstudied for 12 weeks when exercising, and for 12 weeks whennot exercising but maintaining theirregular forms of activity. In this way,each person served as his or herown “control” in the study.


The StudyThe participants for the study weredrawn from the outpatient population at Parkwood Hospital,part of the St. Joseph’s HealthCare Centre in London, Ontario.Potential participants between theages of 18 and 65 were screenedby their own physicians for inclusion in the study. Twenty-fourindividuals completed theprogram.

The FES-assisted bicycling training periods consisted of bicycling three times per week over a period of 12 weeks.Resistance was added once theparticipant was able to ride for 45minutes straight on three consecutive days.

ResultsDoes FES-assisted exercise improvecardiovascular function and thebody’s immune system? Theanswer is a qualified “yes”.Indicators of the status of thesesystems showed small but

statistically significant improvements. Does it helpindividuals develop more stamina

and perform the exercise better?Do participants enjoy this form ofactivity? These answers may bemore compelling. Bicycling performance improved as theweeks went by, and the enthusi-asm and feelings of well-beingamong participants were obvious.Many indicated that it was thepsychological benefit that

enhanced their quality of life. This is not surprising as other studies have shown that exercise itself is great for enhancing feelings of well-being.

“This ONF-funded study adds to a growingbody of informationabout the benefits of FES-assisted activity. This study on its own maynot be ground-breakingbut in the context of theliterature on FES-exercise, the study is making an important

contribution to our existing knowledge.” said Dr. Keith Hayes,Professor of Physical Medicine andRehabilitation at the University ofWestern Ontario, who led theteam of investigators.

The measurable results and the limited number of participantswere insufficient to establish rigorous statistical conclusions. Butself-reports of the incidence andseverity of secondary complications indicate that FES-assisted exercise does benefit participants with respect to secondary conditions like pressure

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ulcers and infections. Ninety-sixpercent of the participants considered the exercise to havebeen good for their health,according to the survey results.

Knowledge Transfer andImplementationAs a result of the study, there wasa groundswell of support to establish a clinical program of FES-assisted bicycling at the community-accessible ParkwoodHospital Fitness Centre in London.Trial participants and medical staff


96%of the

participantsconsidered the

exerciseto have beengood for their

health

lobbied hospital therapists and theadministration to establish the program with a “Try Before YouBuy” approach. Individuals withSCI in the London area who are curious about whether FES-assistedcycling would be beneficial tothem have the opportunity to tryout the system in clinically supervised conditions.

“Participants felt a sense ofreward. Because of this study, anFES-assisted bicycling program isnow established at the hospital,”Hayes said.

on traumatic brain injury. Over aperiod of two years, experts used aconsensus decision makingprocess to devise the Guidelinesdrawing on existing evidence, clinical expertise and externalreviews. The present Guidelines area work in progress, and will likely be updated in a few years.

The Guidelines are available toview or download (7MB) on theONF website. Go to www.onf.organd select “What’s New” .

NOTE: The Guidelines aredesigned to be used by health-care professionals only. If you arean adult who is experiencing persistent symptoms following anmTBI, please make your healthcareprovider aware of these guidelines.

Guidelines for Mild Traumatic

Brain Injury (mTBI) and Persistent Symptoms

months. But 10 to 15% of individuals who sustain an mTBI willcontinue to experience significantsymptoms beyond this anticipatedrecovery period. Persistent symptoms can include post-traumatic headache, sleep disturbance, problems with balance, cognitive impairments,fatigue, and changes in mood.Sometimes persistent symptomsinterfere with an individual’s daily-function, family relationships andability to return to work and liferoles.

Despite frequent mention in thepopular press, mTBI (concussion)treatment remains an evolvingarea of enquiry. The Guidelineswere drawn up with input fromnational and international experts

In March of this year, the OntarioNeurotrauma Foundation releasedthe Guidelines for Mild TraumaticBrain Injury (mTBI) and PersistentSymptoms.

The Guidelines have beendeveloped to help healthcare professionals implement best practices in the care of adults whosustain an mTBI and experiencepersistent symptoms.

An adult who sustains an mTBI,also known as concussion, usuallyrecovers within one week to three

http://onf.org/documents/Guidelines%20for%20Mild%20Traumatic%20Brain%20Injury%20and%20Persistent%20Symptoms.pdf


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GoodNight ?

Many people with a traumatic brain injury (TBI) have trouble sleepingat night. Some also report feeling tired during the day. For a person

with TBI, poor sleep means more than just a long night. Disruptedsleep can slow down rehabilitation and affect outcomes.

Knowing how sleep changes aftera brain injury could help medicalprofessionals target strategies toimprove sleep for people with TBI.The Ontario NeurotraumaFoundation (ONF) recently fundeda studentship for a comprehensiveinvestigation of sleep for individualswith traumatic brain injury.Catherine Milner, cognitive rehabilitation therapist and psychological counsellor, led thestudy as part of her doctoralresearch under the direction of Dr.Kimberly Cote of the Departmentof Psychology at Brock University.

Milner investigated and comparedthe sleep of individuals with a braininjury and those without.

Study participants were drawnfrom Brock University and the community of St. Catharines,Ontario. Forty people with an average age of just under 30 tookpart in the study. Half the participants had traumatic braininjuries ranging from mild to severewhile the other half had no braininjuries.

Three quarters of the participants with TBI reported sleepproblems. Some had trouble

sleeping at night while others experienced daytime tiredness.

Everyone who took part in thestudy was observed sleeping in asleep lab for three nights in a row.In the sleep lab, the brain waves ofthe participants were monitoredwhile they slept. Electrodes,placed on the heads of participants before they went tosleep, sent signals to a computer,which recorded the brain waveactivity.

The first two nights, the investigators observed and

Characterizing sleep after a

traumatic brain injury


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The research also revealed differences between the twogroups in terms of sleep patterns.Each of us has a unique sleep pattern. The sleep pattern of the individuals without brain injuryshowed greater consistency thanthe pattern of participants with TBI.

Milner has a number of ideas forfuture research programs on sleepand people with TBI. She would liketo see a study focus on a singlesleep complaint, i.e. either sleeplessness at night or daytime

monitored participants as theyslept to establish their typical sleeppatterns. During the third night,various tests were conducted.

Sleep is divided into rapid-eyemovement (REM) sleep and non-rapid eye movement sleep(NREM). NREM sleep has particularbrain waves associated with itsfour stages. A person who sleepsseven to eight hours a night willtypically spend most of the night inNREM sleep.

REM sleep, by contrast, produces brain waves that lookvery similar to those producedwhen a brain is awake. A personwill typically have about ninety minutes of REM sleep each night.

In the sleep lab, participantswith TBI generally took longer toget to sleep, displayed moremovement when sleeping, andslept for shorter periods than theparticipants without brain injuries.These differences were reflected inthe brain waves of both groups.The findings focus on differences in the NREM sleep.

The study participants with TBIshowed fewer K-complex waves,which are a type of brain wave

My research is a

first step in beginning to uncover

the reasons for sleep complaints

for people with TBI

produced during the last threestages of NREM sleep. This findingwas true of the participants with TBIregardless of the severity of theinjury. “It is clear that sleep is disrupted after a TBI,” Milner said.

Another finding was that thebrains of participants with TBI weremore alert while sleeping. “Ourfindings show that the brain withan injury is in overdrive,” Milnersaid. “There is clear evidence thatthe brain in participants with TBI ismore engaged during sleep whenit should be resting.”

tiredness. She would also like toinvestigate how medication andpain affect sleep for people withTBI. She thinks that a study focusing on treatments for sleepproblems would also be beneficial.“My research is a first step inbeginning to uncover thereasons for sleep complaints forpeople with TBI,” Milner said. “Astudy that involves a treatmentcomponent to target improvementof sleep prior to rehabilitationwould prove useful.”


HOLD THE DATEKnowledge Mobilization Seminar Series

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May 27th @ 11:30 am

Erin Mills Convention Centre806 Southdown RoadMississauga

Contact CPA Ontario for more information416-422-5644


90 Eglinton Avenue East, Suite 601, Toronto, Ontario, Canada M4P 2Y3

Tel: (416) 422-2228 Fax: (416) 422-1240 Email: [email protected] Website: www.onf.org

support-type cells aftertransplantation.Nobody knows yetwhat the optimumcombination of neurons and supportcells is, but scientistsagree that that theywant to be able to exercisegreater control over what sort ofcell a transplanted stem cellbecomes. “We wanted more control but we’re not sure whatthe ideal formula is yet,” Kim said.

In order to improve both the survival rate and the ability toselect the cell type, Kim tried transplanting the stem cells using acombination of drugs and theinsertion of a simple device.

The device is a tube made fromchitosan (pronounced ky-tow-san),a substance derived and purifiedfrom crustaceans like shrimps. In hisexperiments, Kim placed the twoends of the severed spinal cord ineither end of the tube or channel.The channel contained neuralstem cells that had been treated

with drugs. Kim was hoping thatthe drugs together with the chitosan tubes would improve thesuccess of the stem cell transplantations. He explained,“Stem cells survive better if theyhave something to attach to”.

And it turns out, at least from hisinitial experiments, that Kim has hitupon a winning combination ofdrugs and biomaterials. In his experiments, both the survival rateof the stem cells and the ability tocontrol their transformation werebetter than in the control groups.

As a second part of his research,Kim also investigated the toxicityand durability of the biomaterialchitosan in SCI applications. Hecompared chitosan with two otherbiomaterials commonly used inmedical procedures and concluded that chitosan proved tobe both non-toxic as well as optimally durable for the purposesof spinal cord injury repairs.

Kim is submitting his research toacademic journals for publicationand has given presentations of hispreliminary findings at internationalconferences including the Societyfor Neuroscience conference inChicago. “I think stem cell therapyis very promising,” Kim said, “but Iwould caution against being overly optimistic about the currentstate of the technology. There’s stilla lot we need to learn about howto harness the full potential of stemcells before they can be trulyeffective as part of a cure for SCI.”

What if... a spinal cord could repair itself?

SStem cell research is new andpromising. It offers the possibility ofreversing nervous system damagepreviously assumed to be permanent. Scientists are experimenting with how to applystem cell technology successfullyto remedy conditions like multiplesclerosis, Parkinson’s disease, LouGehrig’s Disease and spinal cordinjury, among many others.

The Ontario NeurotraumaFoundation (ONF) is cautiouslyoptimistic about the potential ofstem cell research. Recently, ONFawarded a studentship grant toHoward Kim, a promising youngscientist at the University ofToronto’s Institute of MedicalScience. Kim is working under thedirection of neurosurgeon ProfessorCharles Tator and biomedicalengineer Professor Molly Shoichet.

Kim’s ONF-funded researchfocuses on the application of adultneural stem cells on spinal cordinjuries. He conducted his experiments on rats whose spinalcords were completely severed. Inthese rats, there was a total loss ofmotor function and sensationbelow the level of injury.

Typically, when neural stem cellsare transplanted into a spinal cord,many of them die. So, one of Kim’sobjectives was to figure out a wayto keep the stem cells alive aftertransplantation.

Neural stem cells have the ability to turn into neurons (themain signalling cell type of thenervous system) or a cell that supports neurons. Typically, themajority of stem cells turn into

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