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BACKGROUND: Although there is a growing body of literature on the impact of multiple concussions on cognitive function with aging, less is known about the long-term impact of sustaining a single mild traumatic brain injury (mTBI). Additionally, very few interventions exist to treat mTBI patients and prevent a possible accelerated cognitive decline. This study aimed to: 1) examine the long-term effects of a single mTBI on cognition in patients aged between 55 and 70 years old; and 2) evaluate the cognitive effects of an aerobic exercise program for these patients. METHODS: Thirty-five participants (average age: 58.89, SD=4.14) were assessed using neuropsychological tests. Among them, 18 hadsustained a mTBI two to seven years earlier. Significant differences in information processing speed, executive function and visual memory were found between controls and mTBI patients. Sixteen of the mTBI patients then engaged in a 12-week physical exercise program. They were divided into equivalent groups: 1) aerobic training (cycle ergometers); or 2) stretching exercises. The participants' cardiopulmonary fitness (VO2max) was evaluated pre- and postintervention and neuropsychological tests were re-administered postintervention. RESULTS: Participants from the aerobic group significantly improved their fitness compared to the stretching group. However, no between-group difference was found on neuropsychological measures postintervention. CONCLUSIONS: In summary, this study shows long-term cognitive effects of mTBI in late adulthood patients. Moreover, the controlled, 12-week aerobic exercise program did not lead to cognitive improvements in our small mTBI sample. Lastly, future directions in optimizing mTBI intervention are discussed.

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OBJECTIVE: Primary motor (M1) cortical excitability alterations are involved in the development and maintenance of chronic pain. Less is known about M1-cortical excitability implications in the acute phase of an orthopedic trauma. This study aims to assess acute M1-cortical excitability in patients with an isolated upper limb fracture (IULF) in relation to pain intensity. METHODS: Eighty-four (56 IULF patients <14 days post-trauma and 28 healthy controls). IULF patients were divided into two subgroups according to pain intensity (mild versus moderate to severe pain). A single transcranial magnetic stimulation (TMS) session was performed over M1 to compare groups on resting motor threshold (rMT), short-intracortical inhibition (SICI), intracortical facilitation (ICF), and long-interval cortical inhibition (LICI). RESULTS: Reduced SICI and ICF were found in IULF patients with moderate to severe pain, whereas mild pain was not associated with M1 alterations. Age, sex, and time since the accident had no influence on TMS measures. DISCUSSION: These findings show altered M1 in the context of acute moderate to severe pain, suggesting early signs of altered GABAergic inhibitory and glutamatergic facilitatory activities.

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OBJECTIVES: This study seeks to evaluate the incidence rate of heterotopic ossification (HO) formation in patients afflicted by an isolated limb fracture (ILF) and a concomitant mild traumatic brain injury (mTBI). METHODS: The current study is an observational study including ILF patients with or without a concomitant mTBI recruited from an orthopedic clinic of a Level 1 Trauma Hospital. Patients were diagnosed with a mTBI according to the American Congress of Rehabilitation Medicine (ACRM) criteria. Radiographs taken on average 3 months post-trauma were analyzed separately by two distinct specialists for the presence of HO proximally to the fracture site (joints or extra joints). Both raters referred to Brooker's and Della's Valle's classification to establish signs of HO. First, analyses were conducted for the full sample. Secondly, a matched cohort was used in order to control for specific factors, namely age, sex, type of injury, and time elapsed between the accident and the analyzed radiograph. RESULTS: The full sample included a total of 183 patients with an ILF (94 females; 47.5 years old), of which 50 had a concomitant mTBI and 133 without. Radiographic evidence of HO was significantly higher in patients with an ILF and a mTBI compared to ILF patients (X2 = 6.50; p = 0.01). The matched cohort consisted of 94 participants (i.e.; 47 patients from the ILF + mTBI group and 47 patients from the ILF group). Again, ILF + mTBI patients presented significantly higher rates of HO signs in comparison to ILF patients (X2 = 3.69; p = 0.04). Presence of HO was associated with prolonged delays to return to work (RTW) only in ILF + mTBI patients (F = 4.055; p = 0.05) but not in ILF patients (F = 0.823; p = 0.37). CONCLUSIONS: Study findings suggest that rates of HO are significantly higher proximally to fracture sites when ILF patients sustain a concomitant mTBI, even after controlling for factors known to influence HO. Moreover, results show that HO is associated with a prolonged RTW only in ILF patients with a concomitant mTBI but not in ILF-only patients. The impact of mTBI on HO formation warrants further attention to detect early signs of HO, to identify shared physiopathological mechanisms and, ultimately, to design targeted therapies.

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Pain is a multifaceted condition and a major ongoing challenge for healthcare professionals having to treat patients in whom pain put them at risk of developing other conditions. Significant efforts have been invested in both clinical and research settings in an attempt to demystify the mechanisms at stake and develop optimal treatments as well as to reduce individual and societal costs. It is now universally accepted that neuroinflammation and central sensitization are two key underlying factors causing pain chronification as they result from maladaptive central nervous system plasticity. Recent research has shown that the mechanisms of action of repetitive transcranial magnetic stimulation (rTMS) make it a particularly promising avenue in treating various pain conditions. This review will first discuss the contribution of neuroinflammation and central sensitization in the transition from acute to chronic pain in traumatically injured patients. A detailed discussion on how rTMS may allow the restoration from maladaptive plasticity in addition to breaking down the chain of events leading to pain chronification will follow. Lastly, this review will provide a theoretical framework of what might constitute optimal rTMS modalities in dealing with pain symptoms in traumatically injured patients based on an integrated perspective of the physiopathological mechanisms underlying pain.

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BACKGROUND: The objective is to explore the effects of concomitant mild traumatic brain injury (mTBI) on return to work (RTW), among patients suffering from an isolated limb fracture. This follow-up study included a total of 170 working age subjects with an isolated limb fracture, and was conducted in a phone interview approximately 1-year post trauma. 41 had experienced an mTBI and 129 did not. METHODS: Data were obtained through a phone interview conducted on average 20.7 months (SD = 9.6 months) post-accident. The main outcome measure was the number of days taken to RTW after the injury. Demographic information was also gathered during the phone interview. Workers' compensation status was obtained through the hospitals' orthopaedic clinic data. RESULTS: The mTBI group took on average 329.7 days (SD = 298.0) to RTW after the injury, as opposed to 150.3 days (SD = 171.3) for the control group (p < 0.001). After excluding patients who received workers' compensation, the mTBI group still missed significantly more days of work (M = 299.4 days; SD = 333.0) than the control group (M = 105.2 days; SD = 121.6) (p < 0.0001). CONCLUSION: This study shows that mTBI increases work disability by preventing working-age individuals from rapidly returning to work.

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OBJECTIVES: This study seeks to evaluate the effects of a mild traumatic brain injury (mTBI) on pain in patients with an isolated limb fracture (ILF) when compared to a matched cohort group with no mTBI (control group). PATIENTS AND METHODS: All subjects included in this observational study suffered from an ILF. Groups were matched according to the type of injury, sex, age, and time since the accident. Main outcome measurements were: Standardized semi-structured interviews at follow-up of a Level I Trauma Center, and a questionnaire on fracture-related pain symptoms. Factors susceptible to influence the perception of pain, such as age, sex, severity of post-concussive symptoms, and worker compensation were also assessed. RESULTS: A total of 68 subjects (36 females; 45 years old) with an ILF were selected, 34 with a comorbid mTBI and 34 without (24/34 with an upper limb fracture per group, 71% of total sample). Patients with mTBI and an ILF reported significantly higher pain scores at the time of assessment (mean: 49days, SD: 34.9), compared to the control group (p<0.0001; mean difference 2.8, 95% confidence interval 1.8-4.0). Correlational analyses show no significant association between the level of pain and factors such as age, sex, severity of post-concussive symptoms, and worker compensation. CONCLUSIONS: Results suggest that mTBI exacerbate perception of pain in the acute phase when occurring with an ILF, and were not explained by age, sex, post-concussive symptoms, or worker compensation. Rather, it appears possible that neurological sequelae induced by mTBI may interfere with the normal recovery of pain following trauma.

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OBJECTIVES: This study compares the incidence rate of mild traumatic brain injury (mild TBI) detected at follow-up visits (retrospective diagnosis) in patients suffering from an isolated limb trauma, with the incidence rate held by the hospital records (prospective diagnosis) of the sampled cohort. This study also seeks to determine which types of fractures present with the highest incidence of mild TBI. PATIENTS AND METHODS: Retrospective assessment of mild TBI among orthopaedic monotrauma patients, randomly selected for participation in an Orthopaedic clinic of a Level I Trauma Hospital. Patients in the remission phase of a limb fracture were recruited between August 2014 and May 2015. No intervention was done (observational study). MAIN OUTCOME MEASUREMENTS: Standardized semi-structured interviews were conducted with all patients to retrospectively assess for mild TBI at the time of the fracture. Emergency room related medical records of all patients were carefully analyzed to determine whether a prospective mild TBI diagnosis was made following the accident. RESULTS: A total of 251 patients were recruited (54% females, Mean age=49). Study interview revealed a 23.5% incidence rate of mild TBI compared to an incidence rate of 8.8% for prospective diagnosis (χ(2)=78.47; p<0.0001). Patients suffering from an upper limb monotrauma (29.6%; n=42/142) are significantly more at risk of sustaining a mild TBI compared to lower limb fractures (15.6%; n=17/109) (χ(2)=6.70; p=0.010). More specifically, patients with a proximal upper limb injury were significantly more at risk of sustaining concomitant mild TBI (40.6%; 26/64) compared to distal upper limb fractures (20.25%; 16/79) (χ(2)=7.07; p=0.008). CONCLUSIONS: Results suggest an important concomitance of mild TBI among orthopaedic trauma patients, the majority of which go undetected during acute care. Patients treated for an upper limb fracture are particularly at risk of sustaining concomitant mild TBI.

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BACKGROUND: Concussions exert persistent effects on asymptomatic athletes, especially women. Among chief mechanisms of concussion recovery are alterations of neuronal plasticity. Olfactory function, often impaired following a concussion, greatly involves plasticity and, therefore, appears as a good candidate to study the deleterious effects of concussions. The BDNF Val66Met polymorphism (BDNFMet), which reduces availability of BDNF in the brain, has surprisingly been associated with better recovery following concussion. OBJECTIVE: This study examines the mediating effect of BDNFMet on olfactory functions in asymptomatic concussed female athletes. METHODS: Participants, 105 female university athletes, were divided into four groups based on their history of concussion (Concussion/No concussion) and BDNF polymorphism (BDNF Val66Val/Val66Met). Odour threshold, discrimination and identification were measured using the Sniffin' Sticks Inventory Test. RESULTS: Concussed female BDNFMet athletes performed significantly better than BDNFVal counterparts on threshold (F(1, 34) = 4.73, p < 0.05), discrimination (F(1, 52) = 5.36, p < 0.05), identification tests (F(1, 52) = 5.65, p < 0.05) and total olfactory scores (F(1, 34) = 9.54, p < 0.05). CONCLUSION: These results support a genotypic effect of the BDNF Val66Met polymorphism on long-term olfactory function following a concussion in young female athletes.

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Sports-related concussions have been shown to lead to persistent subclinical anomalies of the motor and cognitive systems in young asymptomatic athletes. In advancing age, these latent alterations correlate with detectable motor and cognitive function decline. Until now, the interacting effects of concussions and the normal ageing process on white matter tract integrity remain unknown. Here we used a tract-based spatial statistical method to uncover potential white matter tissue damage in 15 retired athletes with a history of concussions, free of comorbid medical conditions. We also investigated potential associations between white matter integrity and declines in cognitive and motor functions. Compared to an age- and education-matched control group of 15 retired athletes without concussions, former athletes with concussions exhibited widespread white matter anomalies along many major association, interhemispheric, and projection tracts. Group contrasts revealed decreases in fractional anisotropy, as well as increases in mean and radial diffusivity measures in the concussed group. These differences were primarily apparent in fronto-parietal networks as well as in the frontal aspect of the corpus callosum. The white matter anomalies uncovered in concussed athletes were significantly associated with a decline in episodic memory and lateral ventricle expansion. Finally, the expected association between frontal white matter integrity and motor learning found in former non-concussed athletes was absent in concussed participants. Together, these results show that advancing age in retired athletes presenting with a history of sports-related concussions is linked to diffuse white matter abnormalities that are consistent with the effects of traumatic axonal injury and exacerbated demyelination. These changes in white matter integrity might explain the cognitive and motor function declines documented in this population.

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