Charactertizing Growth Hormone Deficiency in Traumatic Brain Injury

University of Calgary200 enrolled

Overview

The goal of this observational study is to characterize the impact of growth hormone deficiency (GHD) on quality of life, symptom burden, and sleep in adults with traumatic brain injury (TBI), and to evaluate whether these outcomes improve with growth hormone replacement therapy. The main questions it aims to answer are: * Does quality of life, as measured by the Quality of Life Assessment of Growth Hormone Deficiency in Adults (QoL-AGHDA), differ between adults with TBI and GHD compared to those with TBI and no GHD? * Do fatigue, cognition, mood, post-concussion symptoms, body image, libido, perceived stress, and sleep architecture differ between these two groups? * Among participants with GHD who begin growth hormone replacement therapy, do symptom burden and quality of life improve over a 12-week treatment period? Eligible participants will be asked to complete baseline questionnaires and undergo testing for growth hormone deficiency (glucagon stimulation testing). A subset of participants will also complete objective sleep assessments using actigraphy and at-home polysomnography. For those who are diagnosed with growth hormone deficiency and choose to pursue treatment, questionnaires will be repeated bi-weekly while receiving growth hormone replacement therap

Growth hormone deficiency (GHD) is the most common chronic hormone deficit following traumatic brain injury (TBI) with variable prevalence (average of 10-15%), likely a reflection of the timing and methods of testing, age, and injury severity. Previous guidelines recommend assessment of GHD with serum IGF-1. However, studies have found IGF-1 lacks specificity and sensitivity and does not correlate with dynamic testing in patients with mild TBI and GHD. The primary objective of this observational study is to determine whether the Quality of Life in Adult Growth Hormone Deficiency Assessment (QoL-AGHDA) can aid in predicting GHD in patients with mild TBI. Patients aged 18-75 years with a diagnosis of mild TBI (American congress of rehabilitation 2023 guidelines and Centre for disease control and prevention definition of traumatic brain injury) with persistent symptoms at 1-year post-injury attending the Calgary Brain Injury program and the chronic pain centre will be screened for suspected GHD by physicians. Eligible participants will complete the QoL-AGHDA along with other symptom based measures and will be referred to endocrinology for provocative testing for GHD (glucagon stimulation testing). The secondary objective is to determine if the QoL-AGHDA can provide an objective measure of growth hormone treatment efficacy in patients with TBI and GHD. To address this, participants found to have GHD (peak GH of \<3mcg/L following glucagon stimulation test) will be provided with growth hormone replacement (Genotropin, Pfizer) for 3 months. Participants will be asked to repeat questionnaires (QoL-AGHDA and additional symptom measures) bi-weekly throughout the 3-months of treatment. Exploratory sleep assessment: 1. Participants will be invited to participate in one or both optional sleep components of the study. All participants will be offered 6 consecutive days and nights of wrist actigraphy (MotionWatch8, CamNtech) following completion of the glucagon stimulation test or initial endocrinology appointment. The wrist-worn accelerometer will objectively measure sleep patterns, duration, and rest-activity cycles, while participants will complete a brief daily electronic sleep diary to capture subjective sleep characteristics. Participants diagnosed with GHD will be invited to repeat the actigraphy protocol and sleep diary after 3 months of growth hormone replacement therapy. 2. A subset of approximately 30 participants will also complete two consecutive nights of at-home polysomnography (PSG) using the Nox SAS Solution (Nox Medical, Reykjavik, Iceland). Participants will receive written and video instructions for self-application of the device. The second night of PSG will be used for analysis to characterize objective sleep architecture and identify sleep disturbances using physiological measures including brain activity, respiratory parameters, oxygen saturation, heart rate, body position, and movement. The PSG subgroup will include approximately 10 healthy controls, 10 participants with persistent symptoms following mild TBI without GHD, and 10 participants with persistent symptoms following mild TBI and GHD. Healthy controls will complete baseline demographic and medical history forms, medication use questionnaires, and the Epworth Sleepiness Scale prior to PSG.

Eligibility

Sex: ALLMin age: 18 YearsMax age: 70 YearsHealthy volunteers:

Medical Language ↔ Plain English

Inclusion criteria: Adults aged 18-70 years must be referred and have a diagnosis of mTBI made by a brain injury specialist physician and meet the 2023 ACRM diagnostic criteria (Appendix A, Panel A) or the NIH diagnostic criteria for moderate/severe TBI (Appendix A, Panel B). All participants must be symptomatic for at least one-year post-injury (determined by the Glasgow Extended Scale score of less than 8 for moderate/severe TBI and a Rivermead Post-Concussion Questionnaire score of \> 13 with 3 or more symptoms scored \> 3 for mTBI), at the time of screening. All participants must also be fluent in English and be able to either complete questionnaires online or over the phone. In terms of concomitant therapies and medication, all prescription and non-prescription medications (e.g., over-the-counter drugs and herbal supplements) and therapies will be recorded by participants during baseline assessments. Participants with GHD on treatment will be asked to disclose any changes in medications/and or therapies at each bi-weekly follow up questionnaires. Exclusion criteria include untreated pituitary deficits to minimize confounding factors (unless treated/consulted with Dr. Debert and/or Dr. Lithgow), other intracranial abnormalities, chronic neurological conditions, untreated medical conditions, major medical conditions in the past 6 months such as stroke, and current or planned pregnancy.

Outcomes

Primary Outcomes

Quality of Life in Adult Growth Hormone Deficiency Assessment (Qol-AGHDA)

A 25-question, self-administered, condition specific quality of life measure used to determine the extent to which growth hormone deficiency has affected the patient's quality of life. Participants are instructed to answer "yes" or "no" to statements relating to problems with memory and concentration, tiredness, tenseness, social isolation and self-confidence. Higher scores indicate greater symptom burden and lower quality of life.

Time frame: To be completed at baseline and repeated bi-weekly during Genotropin treatment and treatment completion (3 months)

Glucagon Stimulation Testing

Provocative glucagon stimulation testing completed by endocrinology. Peak growth hormone of less than 3mcg/L indicative of growth hormone deficiency

Time frame: Baseline

Secondary Outcomes

Saint Louis University Mental Status Examination (SLUMS)

Assesses for mild cognitive impairment. Total possible score ranges from 0 to 30, with higher scores indicative of better outcomes.

Time frame: To be assessed at baseline and at completion of treatment (3 months)

Fatigue and Altered Cognition Scale (FACS)

A 20-item self-reported questionnaire that measures central fatigue and altered cognition, , with 10 items comprising each subscale. Items are rated on an electronic visual analog scale (0-100), with higher scores indicating greater symptom severity.

Time frame: To be repeated bi-weekly during Genotropin treatment and treatment completion (3 months)

Patient Health Questionnaire - 9 (PHQ-9)

Assesses depressive symptoms. Total possible score ranges from 0-27, with higher scores indicative of worse outcomes.