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The focus of this article is on the acute management of traumatic brain injury. The article focuses on the classification of traumatic brain injury, general acute management of traumatic brain injury, the role of the physiatrist on this team, and lastly, behavioral and family considerations in the acute care setting. The article includes a focus on physiologic systems, strategies for the management of various aspects of brain injury, and consideration of factors associated with the continuum of care. Overall, the article reviews this critical period of brain injury recovery and provides a primer for the physiatrist.

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West Nile Virus (WNV) is the most common mosquito borne cause of viral encephalitis in the United States. Physical and neuro-cognitive recovery from WNND may be prolonged or incomplete leading to chronic cognitive inefficiencies and functional decline. There continues to be no effective treatment of WNV and current management is primarily supportive. The objective of this review is to evaluate the functional outcomes and role of rehabilitation services in subjects with WNND. The charts of five subjects admitted to an acute inpatient brain injury rehabilitation facility from June to December 2012 were retrospectively reviewed. (Mean, Range)-Age (64.8, 43-78 years), Admission Functional Independence Measure (FIM) (45.2, 14-63), Discharge FIM (82.2, 61-100), FIM score gain (37, 24-60), Cognitive FIM gain (7, 1-18), Mobility FIM gain (17.4, 13-20), ADL FIM gain (12.6, 4-23); acute brain injury inpatient rehabilitation facility length of stay (LOS) (17.8, 14-21 days); acute hospital LOS (15, 10-22 days). Of the five subjects, three were discharged home, one was discharged to a skilled nursing facility, and one was discharged to an assisted living facility. Subjects with WNND have significant functional decline across all FIM subcategories and may benefit from a course of brain injury-specific acute inpatient rehabilitation.

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CONTEXT: Osteopathic cranial manipulative medicine is not a well-established adjunct to conventional treatment for patients with postconcussion symptoms. OBJECTIVE: To determine whether adjunctive osteopathic cranial manipulative medicine is safe for patients with concussion when accompanied by conventional treatments. DESIGN: Prospective observational pilot study. SETTING: Outpatient concussion clinic. PARTICIPANTS: Patients who sustained a concussion were prospectively recruited from an outpatient concussion clinic by a neuropsychologist specialized in concussion. All participants were identified to have a cranial dysfunction. INTERVENTION: Each eligible participant received 1 session of the osteopathic cranial manipulative medicine vault hold technique. MAIN OUTCOME MEASURES: Self-reported adverse events during or after 1 session of the osteopathic cranial manipulative medicine procedure and improvement in concussion symptoms at return to follow-up. RESULTS: None of the 9 participants reported adverse events during or immediately after receiving osteopathic cranial manipulative medicine. Five of the 7 participants who returned for follow-up demonstrated improvement in their overall concussion symptoms based on the Post-Concussion Symptom Scale scores. CONCLUSIONS: Osteopathic cranial manipulative medicine was considered a safe adjunctive treatment option to improve concussion-related symptoms and recovery.

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Return-to-play (RTP) guidelines in concussion management and treatment continue to challenge clinicians, despite recent updates to the protocols and the ongoing media attention. The current guidelines address individualized treatment planning but are difficult to apply to athletes who experience prolonged symptoms, are younger, or have sustained multiple concussions. Recent literature findings have contributed to an improved understanding and applicability of the guidelines while emphasizing a multidisciplinary paradigm in formulating an individualized RTP decision. Successful implementation of the RTP guidelines will ensure that athletes are protected from further injury and return to their baseline functional status.

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BACKGROUND: To determine whether osteopathic medical students, fellows, residents, and practicing physicians differ in their ability to identify inanimate objects and if these skills relate to palpatory experience. METHODS: Fifteen commonly known objects were fixed to a board and blinded with a cotton cloth. In Part I of testing, participants were asked to identify 9 objects, with choices provided. In Part II participants were asked to identify 6 objects using one word only. Part III consisted of identifying the shape of an object in Part II. RESULTS: Eighty-nine osteopathic medical students, fellows, residents, and practicing physicians participated in the study. Overall, correct identification of objects was higher in Part I with choices than in Part II without choices available. No statistically significant difference was found among osteopathic medical students, fellows, residents, and practicing physicians in the correct identification of the objects. CONCLUSIONS: Accuracy in tactile identification of objects among varying levels of palpatory experience was not found. Correlation with clinical palpation cannot be made as it requires a subset of palpatory skills not tested in this study. Accuracy and measurement of palpation should be studied further to demonstrate if palpatory experience improves palpatory accuracy.

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STUDY DESIGN: Qualitative study to identify themes and explore mechanisms underlying recovery of hand function post stroke for individuals discharged from rehabilitation services. PURPOSE OF THE STUDY: Post-stroke hemiparesis frequently results in persistent hand dysfunction; the mechanisms of functional recovery are however poorly understood. We assessed the perspectives of community-dwelling individuals with chronic stroke on their hand function limitations and recovery to explore the feasibility of developing a theoretical framework for understanding the process of continued post-stroke recovery. METHODS: Eight subjects with chronic post-stroke hemiparesis were interviewed and videotaped while they performed a battery of 20 upper limb tasks. Qualitative analysis consisted of two investigators independently reviewing the videotapes and reading the transcribed conversations, identifying significant issues and then comparing their observations to determine common themes and develop emerging concepts. RESULTS: Four core themes pertaining to impairment and recovery of task-specific ability emerged: 1) spasticity can be overcome actively through task-specific attempts to use the affected arm and hand; 2) use of the affected arm can be facilitated by adopting positions that reduce the effect of gravity on the arm or enable gravity to act as a natural assist in the movement; 3) task-specific skill can be attained by repeatedly attempting specific component movements of tasks in the context of a variety of different tasks; and 4) frustration impedes task performance but a mental state of 'detached focus' can improve the motivation to use the affected arm. CONCLUSIONS: These themes suggest a therapeutic framework for continued upper limb rehabilitation in patients' own environment to maximize functional recovery in individuals long after their stroke, and generate hypotheses which may lead to the development of new therapeutic protocols. LEVEL OF EVIDENCE: NA.

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Traumatic brain injuries that occur during sports have gained significant attention in the literature. Despite improved education and research on proper identification, risk management, and treatment, standardized methods for returning an athlete to play after a concussion are lacking in universal applicability. Current return-to-play guidelines are considered appropriate for the majority of athletes who recover within a few weeks. However, applicability of such guidelines becomes difficult when treating those athletes who experience prolonged symptoms or do not have the resources available to adequately manage complex presentations of concussions. Understanding the guidelines with consideration to special populations will assist the treating physician in providing an appropriate and individualized evaluation and treatment plan to safely return an athlete with a concussion back to play without compromising his or her health.

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Over the past decade, significant advances have been made in understanding concussions. Information regarding proper identification, pathophysiology, risks, outcomes, and management protocols has shifted the treatment paradigm from a generalized grading system to an individualized approach. Early identification and timely management of a concussion is necessary to ensure that patients minimize persistent post-concussive symptoms affecting the physical, behavioral, emotional, and cognitive domains. Adolescents are particularly vulnerable to concussions, having greater susceptibility and more prolonged recovery after sustaining an injury. This article aims to inform clinicians on how to improve symptom relief and functional outcomes for adolescent patients with concussion via immediate intervention, neuropsychological management, and pharmacological treatment.

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OBJECTIVE: To evaluate the gross external characteristics of the coronal, lambdoid, and sagittal sutures in human cadaver skulls and determine if a difference exists in terms of patency, sex, and age. METHODS: The coronal, lambdoid, and sagittal sutures were described using a modified grading scale to quantify sutural patency. An open suture was graded as 0, a fused suture as 1, and an obliterated suture as 2, 3, or 4, depending on the extent of obliteration. RESULTS: Thirty-six skulls were examined, including 17 female and 19 male (age range, 56-101 y). When compared with the sagittal suture, the lambdoid suture was significantly more likely to be patent and least likely to be obliterated. No significant difference in suture grades was found between female and male skulls, and no significant difference was found between age and suture grade. CONCLUSION: The prolonged patency of the lambdoid suture may be due to external forces, such as the greater number of muscles affecting the lambdoid suture when compared with the sagittal suture.

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