Aerobic Exercise: Benefits Following Brain Injury
Following a traumatic brain injury (TBI), aerobic exercise promotes cardiovascular fitness, cognitive recovery, and reductions in mood disorders.1
Physical inactivity, increased sedentary behavior, and greater perceived fatigue are commonly reported following TBI.2 Chin et al3 enrolled a small sample of adults with nonpenetrating TBI in a 12-week aerobic training program to assess the impact of vigorous exercise on cardiorespiratory fitness. Participants (N=10) completed a cardiopulmonary exercise test measuring gas exchange during exercise (ie, oxygen consumption and carbon dioxide output), and completed the Fatigue Severity Scale (FSS) at baseline and following the 12-week exercise training. Participants engaged in supervised exercise training on a treadmill for 30 minutes, 3 times per week at a vigorous intensity, maintaining 70% to 80% of heart rate reserve. At the training completion, statistically significant changes were noted in peak oxygen consumption, time to fatigue, and peak work rate. Participants also reported considerably lower fatigue as evidenced by statistically significant decreases in FSS composite scores.
Exercise may promote cognitive recovery via mechanisms such as increasing neural repair and neuroplasticity, modulating neurotransmitter systems, and decreasing neuroinflammation.1In a systematic review of controlled clinical trials and randomized controlled trails with adults with neurologic disorders, McDowell et al reported that aerobic exercise improved cognition, particularly attention and cognitive flexibility in adults with TBI.4
Chin et al enrolled a small volunteer sample of ambulatory adults with chronic, nonpenetrating TBI into a 12-week aerobic exercise training program to determine the effect of exercise on cognitive performance.5 Participants (N = 7) received 30 minutes of supervised vigorous aerobic exercise training on a treadmill, 3 times per week. Cognitive function was assessed at baseline prior to the beginning of aerobic exercise training, and at the completion of the 12-week intervention. Cognitive function was assessed using the Trail Making Test, parts A and B, and the Repeatable Battery for the Assessment of Neuropsychological Status.
About 50% of individuals with TBI report clinically significant levels of anxiety and depression within the first year of injury.6
Weinstein et al7 enrolled 12 ambulatory adults with nonpenetrating TBI into a 12-week aerobic exercise training program to determine the effect of exercise on mood. Changes in mood before and after exercise were measured using the Profile of Mood Status—Short Form (POMS-SF), obtained at baseline (week 1), week 4, week 8, and week 12 (conclusion). The POMS-SF scoring generates a total mood disturbance (TMD) score, with higher scores indicating a more negative mood state. Participants were engaged in 30 minutes of intensive aerobic exercise, 3 times per week. Participants also engaged in a 5- to 10-minute warm-up and cooldown period. The exercise sessions were maintained at 70% to 80% of the participants’ heart rate reserve, which was continuously monitored during exercise. Target range was maintained by adjusting the speed and/or grade of the treadmill. Analyses showed improvement in mood as evidenced by significantly lower TMD scores between weeks 1 and 12. Improvements in mood were detectable after a single exercise bout in week 1. The greatest changes in POMS-SF scores were noted in the Fatigue-Inertia and the Anger-Hostility subscales.
In a pilot study to determine the feasibility of aerobic exercise for lowering depressive symptoms, Schwandt et al enrolled a small sample (N = 4) of community dwelling adults with TBI and residual physical impairments in a 12-week supervised aerobic exercise program.8 The primary outcome measure was the Hamilton Depression Rating Scale (HAMD), administered at baseline, midpoint, and 12 weeks following the conclusion. Additional measures obtained at baseline and at 12 weeks included assessment of functional aerobic capacity (heart rate above 70% of age-predicted maximum), perceived exertion as assessed by the Borg Rating of Perceived Exertion scale, the Rosenberg Self-Esteem Scale, and frequency of attendance. The intervention consisted of a warm-up (stretching or below target heart rate aerobic activity), 30 minutes of intensive aerobic exercise (intensity determined by a score of 5 to 6 on the Borg scale and a heart rate of 60% to 75% of age-predicted maximum), and a 10-minute cooldown. The intervention was delivered 3 times per week for 12 weeks. Participants worked with a research physical therapist to choose from a cycle, treadmill, or recumbent step machine to reach aerobic thresholds. After the 12-week intervention, HAMD scores decreased from the moderate-to-severe and severe levels of depression at baseline, to mild-to-moderate level or no symptoms at program completion. Additionally, heart rate was lower at post intervention, Borg scores were lower indicating less perceived effort, and self-esteem improved as evidenced by higher Rosenberg Self-Esteem Scale scores.
Aerobic exercise is associated with improved outcomes following TBI, not only in cardiovascular fitness but also in cognitive performance and mood disorders. However, many studies are proof-of-concept, pilot, or pre-post observational studies with small sample sizes, and have numerous methodological limitations. Well-designed randomized controlled trials are needed to test the efficacy of aerobic exercise and rehabilitation outcomes.
Dr Seale is the regional director of clinical services at the Centre for Neuro Skills, which operates post-acute brain injury rehabilitation programs in California and Texas. He is licensed in Texas as a chemical dependency counselor and psychological associate with independent practice. He also holds a clinical appointment at the University of Texas Medical Branch (UTMB) in Galveston in the Department of Rehabilitation Sciences.
1. Zang Y, Huang Z, Xia H, et al. The benefits of exercise for outcome improvement following traumatic brain injury: evidence, pitfalls and future perspectives. Exp Neurol. 2022;349:113958.
2. Driver S, Ede A, Dodd Z, et al. What barriers to physical activity do individuals with a recent brain injury face? Disabil Health J. 2012;5(2):117-125.
3. Chin LMK, Chan L, Woolstenhulme JG, et al. Improved cardiorespiratory fitness with aerobic exercise training in individuals with traumatic brain injury. J Head Trauma Rehabil. 2015;30(6):382-390.
4. McDonnell MN, Smith AE, Mackintosh SF. Aerobic exercise to improve cognitive function in adults with neurologic disorders: a systematic review. Arch Phys Med Rehabil. 2011;92(7):1044-1052.
5. Chin LM, Keyser RE, Dsurney J, Chan L. Improved cognitive performance following aerobic exercise training in people with traumatic brain injury. Arch Phys Med Rehabil. 2015;96(4):754-759.
6. Masel BE, DeWitt DS. Traumatic brain injury: a disease process, not an event. J Neurotrauma. 2010;27(8):1529-1540.
7. Weinstein AA, Chin LKM, Collins J, et al. Effect of aerobic exercise training on mood in people with traumatic brain injury: a pilot study. J Head Trauma Rehabil. 2017;32(3):E49-E56.
8. Schwandt M, Harris JE, Thomas S, et al. Feasibility and effect of aerobic exercise for lowering depressive symptoms among individuals with traumatic brain injury: a pilot study. J Head Trauma Rehabil. 2012;27(2):99-103.
Common, inexpensive diabetes drug could cut long COVID risk, study finds
A well-known, inexpensive diabetes drug appears to cut the risk of developing long COVID, hopeful-but-early new research suggests.
The study, published Thursday in the peer-reviewed journal Lancet Infectious Diseases, found outpatient treatment with the drug metformin — a common treatment for Type 2 diabetes — reduced long COVID incidence among infected patients by 41 per cent.
Roughly six per cent of those taking metformin went on to develop the condition, compared to close to 11 per cent of those in the placebo group. Participants on metformin were also less likely to be hospitalized roughly a month after infection by SARS-CoV-2, the virus that causes COVID-19.
“Metformin has clinical benefits when used as outpatient treatment for COVID-19 and is globally available, low-cost and safe,” wrote the research team.
Lead author Dr. Carolyn Bramante, a physician-scientist with the University of Minnesota in Minneapolis, told CBC News that the effect was even larger when metformin was given quickly �— in less than four days — during someone’s infection. She said metformin may be helping patients fight off the virus, or reducing inflammation, though more research is needed to figure out why the drug appears to work.
“Our data don’t suggest anything about whether metformin would treat long COVID in someone who already has it,” she said, “so that’s an important area of research where trials should be done.”
Two other drugs, ivermectin and fluvoxamine, were also studied, but neither made a difference on the incidence of long COVID.
‘Potentially landmark’ findings
The research involved randomized, quadruple-blind trials on roughly 1,400 people at six sites in the U.S., through multiple waves of the pandemic, and looked at both vaccinated and unvaccinated individuals — though only those with first-time infections.
Outside medical experts say it’s one of the more robust studies yet on a potential preventative aimed at long COVID.
“I think it’s a significant start to having a better understanding of the role of metformin in reducing the risk of long COVID,” said Dr. Isaac Bogoch, an infectious diseases specialist with the University Health Network in Toronto. “There’s been hints of data over the last couple of years … this furthers that discussion.”
If confirmed, the findings are “profound and potentially landmark on two distinct counts,” wrote Dr. Jeremy Faust, from Harvard Medical School, in an accompanying commentary in the Lancet.
The paper offers the “first high-quality evidence” showing incidence of long COVID can be reduced through a medical intervention, he wrote, and offers an important medical contribution regarding the very existence of the condition, since “a treatment can only be effective if there is something to treat.”
In a statement, Dr. Frances Williams, professor of genetic epidemiology at King’s College London, cautioned there would need to be extensive use of metformin to realize the study’s seemingly impressive outcomes.
“In total, 564 people were exposed to the drug metformin to prevent 23 hypothetical cases. This means 24 people would need to take metformin to prevent one case of [long COVID].”
Fatigue, ‘brain fog’
Marked by a variety of lingering symptoms such as fatigue, shortness of breath and feelings of ‘brain fog’, and formally known as post COVID-19 condition, long COVID is thought to be less common by this point in the pandemic, largely thanks to widespread protection from vaccinations.
But the condition can still be debilitating for some, including millions of people around the world — including many in Canada — who became infected with earlier SARS-CoV-2 variants before the arrival of vaccines.
While physicians are hopeful the new research may fuel additional study and potentially help bring down long COVID rates even further, there were some key limitations.
For one thing, it only focused on adults between age 30 and 85 who were overweight or had obesity — so the drug’s impact on individuals of other body weights isn’t yet known.
“It’s not entirely clear how generalizable this will be,” Bogoch said.
In his comment for the Lancet, Faust also noted that since the participants were given a diabetes drug, there may be reduced symptoms linked to undiagnosed diabetes among the patients. “Furthermore, the mechanism of action by which metformin might reduce the incidence of long COVID remains unclear,” he wrote.
Dr. Lynora Saxinger, a professor in the division of infectious diseases at the University of Alberta, noted the study didn’t follow long COVID patients using any “standardized criteria.”
But, she said in an email to CBC News, “it still is really positive and encouraging that a treatment in early COVID could reduce risk of prolonged symptoms: additional studies in other patient groups and with more specific long COVID symptom followup will be really helpful.”
Bogoch stressed that, while the drug shows potential, it wouldn’t “solve all of our issues with long COVID.” However, it could become an important tool given its decades-old safety profile, he said.
“If this is something that, indeed, pans out, and if metformin truly has some properties that reduce the risk of developing long COVID, that’s wonderful because it’s a cheap, widely available [drug].”
Hair loss can be difficult, cancer patients say — and some want better access to options – CBC.ca
White Coat Black Art26:30Hair Loss Part I: The trouble with wigs
Cairo Gregory doesn’t think about her hair too often — anymore.
For much of her life, she says she didn’t have the “greatest” relationship with her hair. Gregory, a 16-year-old student in Toronto, had at one point straightened her hair so much, it ended up damaged. So she cut it short — “I hated it,” she said.
But eventually, as she learned to style her hair, she grew to love it. So last year, when her hair started falling out in her second week of chemotherapy for ovarian cancer, she says she found the loss difficult. Like many of those going through chemotherapy, she made the decision to completely shave her head as she started shedding.
“I think that was probably the most upsetting part for me,” she told White Coat, Black Art host Dr. Brian Goldman.
“When it fell out, it was like my entire Instagram [timeline] was just hair videos, like new hairstyles because I’d gotten really into that at that point. So it really sucked when it was like something that actually really, really became important to me at that period of time.”
Despite advances in cancer treatment, little has changed with respect to its effects on hair. Chemotherapy attacks fast-growing cells in the body — including hair. For many patients, that means losing their locks during treatment.
That can have an impact on a person’s self-confidence and how they feel about themselves during treatment. But alternatives, like wigs and cold-capping procedures that can protect a patient’s hair, are out of reach for many patients due to price and availability.
For Gregory, the problem was compounded by a lack of hospital resources and alternative hair options for people of colour, she said.
“There isn’t a pamphlet that they hand out for people with curly hair to go find wigs. There should be one,” she said.
Wigs can be pricey, but free alternatives exist
Losing hair during cancer treatment can be a shocking experience. Some patients say losing hair can make the psychological burden of chemotherapy feel heavier, given they don’t look like themselves.
“Obviously nobody wants to feel sick, but I didn’t want to look sick,” said Tammy Wegener, who was treated for breast cancer in 2022. “I wanted to feel that I had some peace of mind, that my kids had some peace of mind going through all this.”
That’s something Mona Rozdale says she hears often.
“At the end of the day, everybody wants to feel like themselves, and when you strip something that you’re so used to having, you don’t know life without it,” she said.
Rozdale is responsible for the Canadian Cancer Society’s wig and breast prosthetics bank lending program, which is free.
She says wigs can be a helpful solution to those facing hair loss. But they can also be pricey. On average, a good quality wig made from human hair can cost around $2,500, according to Rozdale. But cheaper synthetic wigs are starting to look more realistic.
When Gregory couldn’t find a wig that fit her style — or budget of around $500 — at a hospital boutique, she opted to have her mother’s hairdresser make her one at a discount.
Scalp cooling is resource-intensive
Some people being treated for cancer have kept their natural hair with a process known as scalp cooling or cold capping.
Patients wear an intensely cold helmet before, during and after chemotherapy that constricts blood vessels in the scalp. It involves chilled caps that are swapped out regularly, or a machine that pumps cold liquid through an attached cap. In doing so, chemotherapy is less likely to reach and damage hair follicles, potentially reducing hair loss.
With limited data on its efficacy and a high price tag, however, cold capping is not widely available across Canada.
“The greatest limitation is chair time. It is a resource-rich type of use of the machine,” said Dr. Shannon Salvador, gynecologic oncologist at the Jewish General Hospital in Montreal and an associate professor at McGill University.
“When you have a patient who has to come for chemo every single week, that’s a great deal of time for them and a lot of time in the hospital to be able to come and use the machine.”
But Salvador, who has studied the effectiveness of scalp cooling, says there is evidence it does work for some patients.
In a 2021 study she co-authored, published in the journal Gynecologic Oncology Reports, over half of patients who were on a smaller weekly dose of a chemotherapy drug retained about 50 per cent of their hair when using a cold cap. The cold cap treatment didn’t work for those on a larger dose.
Cold caps limited at Canadian hospitals
Cold capping is not available to people with certain types of cancer, such as blood cancers, and those being treated with certain types of chemotherapy.
White Coat, Black Art reached out to several cancer centres in Canada, and found scalp cooling offered at just a handful of hospitals, often at the patient’s expense.
Wegener, 49, was able to access the treatment for free at Saint John Regional Hospital after a scalp cooling machine was donated by a nurse at the institution.
26:30Hair Loss Part II: Cold Capping
Salvador says she expects hospitals will still rely on donations and external support for scalp cooling technology, rather than funding them directly.
“We need to acknowledge that, in Canada, we are in a socialized health-care system where we need to place the money where it’s going to do the most benefit,” she said.
“Unfortunately that does mean turning away things that are of great emotional benefit to patients, but may not play a great deal in their actual clinical care.”
Cold capping was a success for Wegener, who says during her chemotherapy treatment she noticed only some thinning of her hair and eyebrows. Based on her own experience, she hopes to see it in more places.
“Not that it’s for everybody and not everybody sees the results I saw with mine,” Wegener said. “But I think it still should be an option for everyone.”
Gregory, the Toronto student who is still anxious about her cancer potentially returning, has become more comfortable with — and without — her wig.
She went to class bald for the first three months of the school year, in part because she also lost hair on and around her face, making the wig look unnatural. But she has since confidently worn wigs to school, and now has enough of her natural hair to add in braids.
“That took a year. It’s almost been a year since my hair started going back,” she said.
“I think by next summer I could probably wear a ponytail wig and then hopefully, like maybe a few summers after that, I won’t wear wigs anymore at all.”
Addictions counselling services expanded for Vancouver Islanders
People struggling with mental health and substance abuse can access up to 12 free counselling sessions per year in a new Island Health program.
Leah Hollins, Island Health Board Chair, says “This represents a significant expansion and investment in community-based counselling services to improve access to these services on Vancouver Island.”
Virtual Island-wide services will be available through Cognito Health, and Trafalgar Addiction Treatment Centre. Services are also available in Port Hardy through North Island Crisis and Counselling Services and in Nanaimo through EHN Outpatient Services and Tillicum Lelum Aboriginal Society.
The publicly-funded, community-based counselling is intended for people with moderate challenges. The new partnership with Island health will meet the counselling needs of at least 1,500 people per year.
Access to the counselling services is via referral or self-referral through Island Health Mental Health and Substance Use locations.
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