Robert L Ruff

Walter Reed National Military Medical Center, Washington, D. C., DC, United States

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Publications (70)250.14 Total impact

  • JAMA Psychiatry 01/2014; 71(1):94. · 12.01 Impact Factor
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    ABSTRACT: Concussions are more serious than previously believed, and awareness of this fact has been increasing in both military and sports settings. Also known as mild traumatic brain injury (mTBI), concussions often occur multiple times in the same service member or athlete. These brain injuries can seriously and negatively affect patients, leading to changes in personality, sleep problems, and cognitive impairments. They can also increase the risk for suicide, posttraumatic stress disorder, depression, and anxiety. In some people, repetitive mTBI can lead to chronic traumatic encephalopathy (CTE), a neurodegenerative disorder. Evidence-based treatments are needed for both mTBI and CTE. Currently, symptom management and patient education are the best strategies to help those who have received multiple concussions. Education about preventing concussions and the use of return-to-play guidelines are especially important for young athletes.
    The Journal of Clinical Psychiatry 08/2013; 74(8):e17. · 5.81 Impact Factor
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    ABSTRACT: Post-traumatic headache (PTH) is the most frequent symptom after traumatic brain injury (TBI). We review the epidemiology and characterization of PTH in military and civilian settings. PTH appears to be more likely to develop following mild TBI (concussion) compared with moderate or severe TBI. PTH often clinically resembles primary headache disorders, usually migraine. For migraine-like PTH, individuals who had the most severe headache pain had the highest headache frequencies. Based on studies to date in both civilian and military settings, we recommend changes to the current definition of PTH. Anxiety disorders such as post-traumatic stress disorder (PTSD) are frequently associated with TBI, especially in military populations and in combat settings. PTSD can complicate treatment of PTH as a comorbid condition of post-concussion syndrome. PTH should not be treated as an isolated condition. Comorbid conditions such as PTSD and sleep disturbances also need to be treated. Double-blind placebo-controlled trials in PTH population are necessary to see whether similar phenotypes in the primary headache disorders and PTH will respond similarly to treatment. Until blinded treatment trials are completed, we suggest that, when possible, PTH be treated as one would treat the primary headache disorder(s) that the PTH most closely resembles.
    Headache The Journal of Head and Face Pain 06/2013; 53(6):881-900. · 2.94 Impact Factor
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    The Journal of Clinical Psychiatry 02/2013; 74(2):180-8. · 5.81 Impact Factor
  • Annals of the New York Academy of Sciences 12/2012; 1275(1):vii-viii. · 4.38 Impact Factor
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    ABSTRACT: This was an observational study of a cohort of 63 Operation Iraqi Freedom/Operation Enduring Freedom veterans with mild traumatic brain injury (mTBI) associated with an explosion. They had headaches, residual neurological deficits (NDs) on neurological examination, and posttraumatic stress disorder (PTSD) and were seen on average 2.5 years after their last mTBI. We treated them with sleep hygiene counseling and oral prazosin. We monitored headache severity, daytime sleepiness using the Epworth Sleepiness Scale, cognitive performance using the Montreal Cognitive Assessment test, and the presence of NDs. We quantitatively measured olfaction and assessed PTSD severity using the PTSD Checklist-Military Version. Nine weeks after starting sleep counseling and bedtime prazosin, the veterans' headache severity decreased, cognitive function as assayed with a brief screening tool improved, and daytime sleepiness diminished. Six months after completing treatment, the veterans demonstrated additional improvement in headache severity and daytime sleepiness and their improvements in cognitive function persisted. There were no changes in the prevalence of NDs or olfaction scores. Clinical improvements correlated with reduced PTSD severity and daytime sleepiness. The data suggested that reduced clinical manifestations following mTBI correlated with PTSD severity and improvement in sleep, but not the presence of NDs or olfaction impairment.
    The Journal of Rehabilitation Research and Development 12/2012; 49(9):1305-20. · 1.78 Impact Factor
  • Annals of the New York Academy of Sciences 12/2012; 1274(1):vii-viii. · 4.38 Impact Factor
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    ABSTRACT: An appropriate density of acetylcholine receptors (AChRs) and Na(+) channels (NaChs) in the normal neuromuscular junction (NMJ) determines the magnitude of safety factor (SF) that guarantees fidelity of neuromuscular transmission. In myasthenia gravis (MG), an overall simplification of the postsynaptic folding secondary to NMJ destruction results in AChRs and NaChs depletion. Loss of AChRs and NaChs accounts, respectively, for 59% and 40% reduction of the SF at the endplate, which manifests as neuromuscular transmission failure. The extraocular muscles (EOM) have physiologically less developed postsynaptic folding, hence a lower baseline SF, which predisposes them to dysfunction in MG and development of fatigue during "high performance" eye movements, such as saccades. However, saccades in MG show stereotyped, conjugate initial components, similar to normal, which might reflect preserved neuromuscular transmission fidelity at the NMJ of the fast, pale global fibers, which have better developed postsynaptic folding than other extraocular fibers.
    Annals of the New York Academy of Sciences 12/2012; 1275(1):129-35. · 4.38 Impact Factor
  • Robert L Ruff, Ronald G Riechers
    JAMA The Journal of the American Medical Association 11/2012; 308(19):2032-3. · 29.98 Impact Factor
  • Robert L Ruff, Paul Rutecki
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    ABSTRACT: The skeletal muscle acetylcholine receptor (AChR) is a beautifully functional molecular complex made up of 5 subunits. Acetylcholine binding initiates pore opening, producing the endplate current (EPC); the resulting action potentials travel over the muscle surface and into the transverse tubules, initiating contraction via calcium (Ca(2+)) release from the sarcoplasmic reticulum that interfaces with the transverse tubule network. EPC amplitude and duration is critical for proper functioning of skeletal muscle: if too small or short, it will not effectively activate sodium channels to trigger action potentials; if too long, it will trigger multiple APs. The EPC also conducts Ca(2+) into cells, so overly long EPCs will lead to endplate damage due to Ca(2+) activation of internal protease systems.(1) Congenital disorders of neuromuscular transmission (CDNT), also called congenital myasthenias, allow us to explore the consequences of natural molecular experiments resulting in alteration of structure on the functioning of the AChR. The article by Shen et al.(2) illustrates the importance of precise timing of the EPC and provides insights into the molecular operation of the AChR.
    Neurology 05/2012; 79(5):404-5. · 8.30 Impact Factor
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    ABSTRACT: Mild traumatic brain injury (mTBI) is a common injury among military personnel serving in Iraq or Afghanistan. The impact of repeated episodes of combat mTBI is unknown. To evaluate relationships among mTBI, post-traumatic stress disorder (PTSD) and neurological deficits (NDs) in US veterans who served in Iraq or Afghanistan. This was a case-control study. From 2091 veterans screened for traumatic brain injury, the authors studied 126 who sustained mTBI with one or more episodes of loss of consciousness (LOC) in combat. Comparison groups: 21 combat veterans who had definite or possible episodes of mTBI without LOC and 21 veterans who sustained mTBI with LOC as civilians. Among combat veterans with mTBI, 52% had NDs, 66% had PTSD and 50% had PTSD and an ND. Impaired olfaction was the most common ND, found in 65 veterans. The prevalence of an ND or PTSD correlated with the number of mTBI exposures with LOC. The prevalence of an ND or PTSD was >90% for more than five episodes of LOC. Severity of PTSD and impairment of olfaction increased with number of LOC episodes. The prevalence of an ND for the 34 combat veterans with one episode of LOC (4/34=11.8%) was similar to that of the 21 veterans of similar age and educational background who sustained civilian mTBI with one episode of LOC (2/21=9.5%, p-NS). Impaired olfaction was the most frequently recognised ND. Repeated episodes of combat mTBI were associated with increased likelihood of PTSD and an ND. Combat setting may not increase the likelihood of an ND. Two possible connections between mTBI and PTSD are (1) that circumstances leading to combat mTBI likely involve severe psychological trauma and (2) that altered cerebral functioning following mTBI may increase the likelihood that a traumatic event results in PTSD.
    BMJ Open 01/2012; 2(2):e000312. · 2.06 Impact Factor
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    ABSTRACT: Background / Purpose: Traumatic brain injury (TBI), particularly mild TBI, is a frequent occurrence for military personnel who served in the conflicts in Iraq and Afghanistan in the early 21st century. Mild TBI is also frequently associated with post-traumatic stress disorder (PTSD). This study evaluated the development of neurological deficits and PTSD with the number of episodes of mild TBI. Main conclusion: We found that the likelihood of an individual having a neurological deficit or PTSD was strongly correlated with the number of episodes of mild TBI with LOC. Furthermore, impaired olfaction was the most sensitive neurological finding that could be evaluated by a physical examination in a clinical setting.
    4th Annual Trauma Spectrum Conference 2011; 12/2011
  • Robert L Ruff
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    ABSTRACT: The neuromuscular junction (NMJ), for most extremity and axial skeletal muscle fibers, with the exception of extraocular, middle ear, and some facial and pharyngeal muscles, is a 'slave' synapse that is designed to activate the muscle fiber every time the nerve terminal is activated. The fidelity of the NMJ hinges upon the electrical depolarization produced by activation of acetylcholine receptors (AChRs), called the endplate potential (EPP), being larger than is needed to trigger an action potential (AP) in the skeletal muscle fiber. The safety factor (SF) is a measure of how much larger the EPP is than the depolarization needed to trigger an AP (EAP). The SF depends on the amount of transmitter released, AChR density, EAP, and the effectiveness of the EPP in stimulating the Na(+) channels that trigger the AP. This study focuses on the postsynaptic factors that influence the SF and how the SF is altered in myasthenia gravis.
    Muscle & Nerve 12/2011; 44(6):854-61. · 2.31 Impact Factor
  • Article: Reply.
    Henry J Kaminski, Gary Cutter, Robert L Ruff
    Muscle & Nerve 12/2011; 44(6):1001. · 2.31 Impact Factor
  • Neurology 10/2011; 77(17):e101-2; author reply e103-4. · 8.30 Impact Factor
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    ABSTRACT: Acetylcholine receptors (AchRs) and Na(+) channels (NaChs) are concentrated on neuromuscular junction (NMJ) postsynaptic folds; both are depleted in myasthenia gravis (MG), reducing the safety factor (SF) for neuromuscular transmission, especially in extraocular muscles (EOM). Studies of human myasthenic nerve-muscle preparations indicate that loss of endplate AChRs accounts for 59%, and NaChs for 40%, of SF reduction. Rodent models of MG indicate that NaChs and AChRs losses are due to complement-mediated destruction of postsynaptic folding. Saccades in MG show stereotyped, conjugate initial components, similar to normal but different from early disconjugacy with ocular nerve palsies. Loss of AChRs, NaChs, and postsynaptic folding all contribute to SF reduction in MG. EOM seem more susceptible to MG because of poor postsynaptic folding, lower baseline SF, and lower levels of intrinsic complement inhibitors. Initial conjugacy of saccades in MG reflects selective sparing of neuromuscular transmission of fast, pale global fibers, which have better developed postsynaptic folding.
    Annals of the New York Academy of Sciences 09/2011; 1233:26-33. · 4.38 Impact Factor
  • Robert L Ruff
    Neurology 05/2011; 76(19):1614-5. · 8.30 Impact Factor
  • Muscle & Nerve 05/2011; 43(5):625-6. · 2.31 Impact Factor
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    ABSTRACT: No single intervention restores the coordinated components of gait after stroke. The authors tested the multimodal Gait Training Protocol, with or without functional electrical stimulation (FES), to improve volitional walking (without FES) in patients with persistent (>6 months) dyscoordinated gait. A total of 53 subjects were stratified and randomly allocated to either FES with intramuscular (IM) electrodes (FES-IM) or No-FES. Both groups received 1.5-hour training sessions 4 times a week for 12 weeks of coordination exercises, body weight-supported treadmill training (BWSTT), and over-ground walking, provided with FES-IM or No-FES. The primary outcome was the Gait Assessment and Intervention Tool (G.A.I.T.) of coordinated movement components, with secondary measures, including manual muscle testing, isolated leg movements (Fugl-Meyer scale), 6-Minute Walk Test, and Locomotion/Mobility subscale of the Functional Independence Measure (FIM). No baseline differences in subject characteristics and measures were found. The G.A.I.T. showed an additive advantage with FES-IM versus No-FES (parameter statistic 1.10; P = .045, 95% CI = 0.023-2.179) at the end of training. For both FES-IM and No-FES, a within-group, pre/posttreatment gain was present for all measures (P < .05), and a continued benefit from mid- to posttreatment (P < .05) was present. For FES-IM, recovered coordinated gait persisted at 6-month follow-up but not for No-FES. Improved gait coordination and function were produced by the multimodal Gait Training Protocol. FES-IM added significant gains that were maintained for 6 months after the completion of training.
    Neurorehabilitation and neural repair 04/2011; 25(7):588-96. · 4.28 Impact Factor
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    ABSTRACT: The purpose was to determine timing characteristics of leg muscle latencies for patients following stroke (>12 months) who had persistent coordination and gait deficits, and to determine the relationships among abnormal latencies, dyscoordination, and gait deficits. We compared nine healthy controls and 27 stroke survivors. Surface electromyography measured activation and deactivation latencies of knee flexor and extensor muscles during a ballistic knee flexion task, consistency of latencies across repetitions, and close coupling between agonist and antagonist muscle latencies. We measured Fugl-Meyer (FM) coordination and the functional gait measure, six minute walk test (6MWT). For stroke subjects, there were significant delays of muscle activation and deactivation, abnormal inconsistency, and abnormal decoupled agonist and antagonist activations. There was good correlation between activation latencies and FM and 6MWT. Results suggest abnormal timing characteristics underlie coordination impairment and dysfunctional gait. These abnormal muscle activation and deactivation timing characteristics are important targets for rehabilitation.
    Rehabilitation research and practice. 01/2011; 2011:313980.

Publication Stats

734 Citations
250.14 Total Impact Points

Institutions

  • 2013
    • Walter Reed National Military Medical Center
      • Department of Neurology
      Washington, D. C., DC, United States
    • University of Washington Seattle
      • Department of Psychiatry and Behavioral Sciences
      Seattle, WA, United States
  • 2007–2012
    • U.S. Department of Veterans Affairs
      Washington, Washington, D.C., United States
  • 2002–2012
    • Louis Stokes Cleveland VA Medical Center
      Cleveland, Ohio, United States
    • University of Massachusetts Amherst
      • Department of Biology
      Amherst Center, MA, United States
  • 1994–2012
    • Case Western Reserve University School of Medicine
      • Department of Neurology
      Cleveland, Ohio, United States
  • 2011
    • University Hospitals
      Cleveland, Ohio, United States
  • 2000–2011
    • Case Western Reserve University
      • • Louis Stokes Cleveland Veterans Administration Medical Center
      • • Department of Neurology (University Hospitals Case Medical Center)
      Cleveland, OH, United States