Males and females from 18-50 years of age who present to a recruitment site within 10 days of injury with a diagnosed concussion that meets all of the following criteria: 1) clear mechanism of injury (i.e., direct or indirect impact to head), 2) Glasgow Coma Scale= 13-15, 3) observed or reported signs (e.g., loss of consciousness, amnesia, or confusion) or symptoms (e.g., headache, dizziness, nausea), and 3) neurosensory symptoms.

Age- and sex-matched control subjects with minor, non-surgical injuries (e.g., sprains, strains) not requiring hospital admission and no history of mild traumatic brain injury will be recruited from the same study sites.

Mild Traumatic Brain Injury

Diagnostic test

Naval Medical Center San Diego

University of Miami

University of Pittsburgh

Standardized Instruments to Provide Diagnostic and Prognostic Information in Mild Traumatic Brain Injury (mTBI)

First predictive saccade to target in a series. Range:1-24. A lower score is better.

Percent of pro-saccadic errors. Range: 0-100%. A lower score is better.

Two factor discriminant function classifier for mTBI versus Control subjects

Comparison of performance in the right and left direction. Range: 0-100%. Lower value is better

Comparison of performance in the right and left direction. Range: 0-100%. Lower value is better.

Patients verbally rate changes in headache, dizziness, nausea and fogginess symptoms compared to their immediate pre-assessment state on a scale of 0 (none) to 10 (severe) following each of the following tasks: 1) smooth pursuit, 2) horizontal and vertical saccades, 3) convergence, 4) horizontal and vertical vestibular ocular reflex (VOR) and 5) visual motion sensitivity (VMS). A near convergence point is also measured. Lower scores are better on each component.

ImPACT is a computerized neurocognitive test that includes six modules: 1) verbal memory, 2) design memory, 3) X's and O's, 4) symbol matching, 5) color matching, and 6) three letter memory (ImPACT Applications Inc.). These modules are used to form four composite scores: verbal and visual memory (%), visual motor processing speed (#), and reaction time (RT) (sec). The ImPACT also includes the Post-concussion Symptom Scale (PCSS), which is a 22-item self-reported symptom severity inventory of somatic, cognitive, affective and sleep-related symptoms. Both composite and item scores are used.

ANAM is a computerized neurocognitive test that includes eight test modules: 1) code substitution delayed, 2) code substitution, 3) matching to sample, 4) mathematical processing, 5) procedural reaction time, 6) simple reaction time, 7) simple reaction time repeated, and 8) go/no go (ANAM v. 4.3; Vista Life Sciences). These modules are scored based on accuracy, speed, and throughput (accuracy/mean reaction time). Both composite and item scores are used

First, the lens-corrected static visual acuity will be assessed using a standard Snellen or LogMAR eye chart. The lowest line that all letters can be read will be recorded. For dynamic visual acuity, the patient will flex their head down 30 deg, then rotate their head in the yaw plane at a frequency of about 2 Hz and amplitude of 20-30 deg. A metronome will be used to set the frequency. Again, the lowest line that all letters can be read will be recorded. A loss of greater than 2 lines suggests an impaired vestibulo-ocular reflex.

The BESS measures postural stability and consists of three stances including feet side by side, a tandem stance, and a single-leg stance on the non-dominant leg. The three stances are performed for 20 sec each on a firm surface. All stances are completed with eyes closed and with hands on the iliac crests. Errors include lifting hands off the iliac crests, opening the eyes, stepping, stumbling, or falling, moving the hip into more than a 30 degree of flexion or abduction, lifting the forefoot or heel, or remaining out of the testing position for more than 5 seconds. Each error equals 1 point, with higher scores indicating worse performance.

The NSI is a 22-item (i.e. symptom) scale in which participants rate the severity of symptoms on a 5-point scale (0 = None, 1 = Mild, 2 = Moderate, 3 = Severe, 4 = Very Severe) ranging from 0-60. Both composite and item scores will be analyzed.

The VVAS assesses how much dizziness (0-10 visual analog scale) an individual reports for 9 different activities. A rating of at least two of the nine items on the VVAS above zero indicates impairment.

The DHI is a 25-item self-report measure that examines dizziness-related handicap. Both domain summary scores and individual ratings will be used. A low score indicates normal function.

The BSI-18 is an 18-item symptom inventory that assesses the level of psychological distress during the past 7 days on 18 items. The BSI-18 yields total global severity index ranging from 0-72, as well as somatic, depression, and anxiety sub-scale scores. Any sub-scale T-score >63 is reflective of clinical impairment on that sub-scale.

The PSQI will be used to assess sleep quality. The PSQI is a self-report measure including 18 items that comprise seven component scores: 1) subjective sleep quality, 2) sleep latency, 3) sleep duration, 4) sleep efficiency, 5) sleep disturbances, 6) sleep medication usage, and 7) daytime dysfunction. Subscale and global PSQI scores are calculated, with higher scores indicating poorer sleep quality.

Data will be shared with the Uniformed Services University Data Repository, as specified by the award agreement with the University of Pittsburgh.

Carey Balaban

Professor

Uniformed Services University of the Health Sciences

United States Naval Medical Center, San Diego

Exposure to still pictures from the same VR scene but no balance challenge

Standard CBT protocol for the treatment of panic disorder

Panic Disorder

Proprioceptive Disorders

Computer Assisted Rehabilitation Environment Integrated Reality System used for the challenge of balance control

VR movie + balance challenge

Monitoring only still pictures from the VR scene in a loop, no balance challenge

still pictures from VR

Cognitive Behavioral Therapy

Sheba Medical Center, Sheba Rehabilitation Center for Advanced Technologies

The Assessment and Treatment of Balance Impairment Using Virtual Reality (VR) in Panic Disorder Patients

The investigators will evaluate panic and anxiety levels on week 1, and then examine whether there was a change in panic or anxiety levels on weeks 5 and 11.

The investigators will evaluate balance impairment levels on week 1, and then examine whether there was a change in balance levels on weeks 5 and 11.

The investigators will measure blood pressure on week 1 and then evaluate whether there was a change in blood pressure on weeks 5 and 11.

The investigators will measure the heart rate on week 1 and then evaluate whether there was a change in heart rate on weeks 5 and 11.

yaws/nàusea

Standardized Instruments to Provide Diagnostic and Prognostic Information in Mild Traumatic Brain Injury (mTBI)

The Assessment and Treatment of Balance Impairment Using Virtual Reality (VR) in Panic Disorder Patients

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