Photobiomodulation to Improve Cognition in TBI, With fMRI

Objectives: This small study examines effectiveness of an at-home experimental intervention that utilizes near-infrared (NIR) wavelengths of light (810nm) applied to the scalp, using light-emitting diodes (LEDs), to improve brain function. LEDs may directly improve the cellular activity of brain tissue that has been damaged by brain trauma. The intervention involves two series of 15 treatments, which are self-administered, at-home. Neuropsychological testing and structural and functional MRI (fMRI) scans will be administered to examine behavioral and brain changes before and after a series of LED treatments. MRI scans will examine some mechanism of LED intervention including changes in blood flow, functional connectivity and neurochemicals. Research Design: This study is a blinded, randomized, sham-controlled, partial-crossover study, with 2 groups (n=10 per group (Sham, Real); ages 18-65). Participants are randomized, by computer into groups. At-home LED intervention is self-administered 3 times per week (20 minutes), for two 5-week series, with a one-month break between series. Group 1 receives both a series of Sham and a series of Real treatments and Group 2 receives two series of Real treatments. All participants will receive at least one series of Real treatments during participation. Methods and General Study Procedure: Twenty veterans with traumatic brain injury, 18-65 years old, who are at least 6-months post- the latest mild-moderate traumatic brain injury (TBI) will be studied. A 1-hour, In-office neuropsychological (NP) screening, after consenting, will determine study eligibility and ensure participants meet the inclusion/exclusion criteria. Participants may be in the study for about 4 months. Device Parameters: Vielight Neuro Alpha head frame device, NIR, 810nm, pulsed at 10 Hz, 50% duty cycle, 20-minute treatment with automatic shutoff. Total Energy Dose per head set plus intranasal: 225 J/cm2+ 15 J/cm2 = 240 J/cm2 per 20 min LED treatment. Total Energy Dose delivered (3x/Week, 5 Weeks) = 3600 J/cm2. The light from these LEDs is not visible to the eye. There is no potential for eye damage because the LEDs are not laser light. Sham and Real devices are identical in look and feel, except no photons are emitted from the Sham devices. The head frame device falls within the FDA category General Wellness, low-risk devices, and no medical claims are made. It is approved for use by the VA Boston Healthcare System Safety and Human Subjects Committees. Training: Each participant is assigned his/her own LED head frame device for hygiene reasons. The assigned device will be provided to each participant at a 1-hour in-office training session, after the first Neuropsychological (NP) Testing. Training that includes both verbal and written instructions will be provided, along with demonstration of use of the device. A treatment log, storage box and alcohol wipes for cleaning are provided. The first treatment is completed at the training session. For each series of LED treatments, a 20-minute, LED treatment is completed at home, 3 times per week (Monday, Wednesday, and Friday), for 5 weeks. There must be at least 48 hours between treatments. There will be a total of 15 treatments in each series. The specific time of day is at the participant's convenience. Missed treatments will be completed at the end of the 5-week series, so all participants will complete all 15 LED treatments. If more than 1 treatment session in a week is not completed, due to unforeseen circumstances, the participant may be withdrawn from the study. A staff person will telephone each participant weekly, to fill out a questionnaire about the intervention including inquiring if the LED treatments are being performed, if the treatment log sheets are being filled out, and note if there are any questions, concerns or problems. Neuropsychological Testing: All NP testing is completed at the VA Boston Healthcare System, Jamaica Plain Campus, Boston, MA. NP tests are administered at four time points (pre- intervention, with follow-up testing at 1 week and 1 month post- series 1, and 1 week post- series 2): The California Verbal Learning Test (CVLT), Long-Delay Free Recall (LDFR) is the Primary Outcome Measure which examines verbal learning, organization and memory. The subtest LDFR, CVLT-II specifically assesses long-delay (20 min), verbal memory, which can be affected after mild-moderate brain injury. Other NP, Psychosocial and General Health measures are considered Secondary Outcome Measures. To avoid practice effects, alternate versions of the NP tests will be used at the Post- LED testing times, when feasible. Imaging will be conducted on the 3T Philips MRI system located at the Boston University Center for Biomedical Imaging (BU CBI). One-hour scans are acquired at 3 time points, in all participants. No contrast or x-rays are used. Participants are permitted to have an MRI brain scan, if it has been determined at Entry, that MRI scanning would be safe using an MRI safety checklist. On the day of the MRI scan at the BU CBI, the BU Safety Checklist will also be reviewed before any scanning will occur. The light therapy portion of the study may be completed, even if participants cannot undergo MRI scanning for medical or safety reasons. Functional MRI: resting-state functional-connectivity Magnetic Resonance Imaging (rs-fc MRI) is the Primary Imaging Outcome Measure. Rs-fc MRI examines the correlation of low frequency signal between voxels in the brain in different areas. Rs-fc MRI abnormalities have been shown in mild-moderate TBI cases. Other imaging sequences are considered exploratory measures. These will provide information on brain structure, blood flow and neurochemicals. Statistical Analysis Plan Neuropsychological, Psychosocial, and Health Data Analysis: VA Biostatistician, Robert Lew, PhD. This study has two 5-week Series (I and II). In Series I, 10 subjects will be assigned to (A), and 10 assigned to (B). In Series II, all remaining A-subjects will continue on A, and all remaining B subjects will switch to A. Switching increases power and reduces dropout. For subjects in treatment B and then A, the model will include a compound symmetry correlation term (r=0.30). Treated subjects are Series I A; and Series II, switch-to-A. To test if the change between consecutive times, delta, is positive for A, we will model the response, as measured by the CVLT, LDFR in mixed design random effects model of analysis. The formal hypothesis test is a linear contrast, a t-test that assumes an effect size of 0.5. For all Secondary Outcome Measures, exploratory analyses will confirm or not the results for primary hypothesis, CVLT, LDFR. A mixed design random effects model should enable handling of missing data points. Statistical Analyses for MRI/fMRI data MRI data will be analyzed using Matlab, parametric statistics, and available standard Imaging software. All analyses will be parametric and corrections for multiple comparisons will be made. Between group comparison of MRI data for the active vs. control groups (at time points T1-T3) will be completed. Longitudinal impact of treatment over time on MRI scans Analyses will be a within-subject design, which compares changes pre- to 1-week post- and 1-month post- Series 1 intervention.