Robert L Ruff

Case Western Reserve University School of Medicine, Cleveland, Ohio, United States

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Publications (132)566.53 Total impact

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    ABSTRACT: Chronic pain, especially headache, is an exceedingly common complication of traumatic brain injury (TBI). In fact, paradoxically, the milder the TBI, the more likely one is to develop headaches. The environment of injury and the associated comorbidities can have a significant impact on the frequency and severity of headaches and commonly serve to direct management of the headaches. Trauma likely contributes to the development of headaches via alterations in neuronal signaling, inflammation, and musculoskeletal changes. The clinical picture of the patient with post-traumatic headaches is often that of a mixed headache disorder with features of tension-type headaches as well as migrainous headaches. Treatment of these headaches is thus often guided by the predominant characteristics of the headaches and can include pharmacologic and nonpharmacologic strategies. Pharmacologic therapies include both abortive and prophylactic agents with prophylaxis targeting comorbidities, primarily impaired sleep. Nonpharmacologic interventions for post-traumatic headaches include thermal and physical modalities as well as cognitive behavioral approaches. As with many postconcussive symptoms, headaches can lessen with time but in up to 25% of patients, chronic headaches are long-term residua. © 2015 Elsevier B.V. All rights reserved.
    Handbook of Clinical Neurology 12/2015; 128C:567-578. DOI:10.1016/B978-0-444-63521-1.00036-4
  • JAMA Psychiatry 01/2014; 71(1):94. DOI:10.1001/jamapsychiatry.2013.2989 · 12.01 Impact Factor
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    ABSTRACT: Many patients with an acute stroke live in areas without ready access to a Primary or Comprehensive Stroke Center. The formation of care facilities that meet the needs of these patients might improve their care and outcomes and guide them and emergency responders to such centers within a stroke system of care. The Brain Attack Coalition conducted an electronic search of the English medical literature from January 2000 to December 2012 to identify care elements and processes shown to be beneficial for acute stroke care. We used evidence grading and consensus paradigms to synthesize recommendations for Acute Stroke-Ready Hospitals (ASRHs). Several key elements for an ASRH were identified, including acute stroke teams, written care protocols, involvement of emergency medical services and emergency department, and rapid laboratory and neuroimaging testing. Unique aspects include the use of telemedicine, hospital transfer protocols, and drip and ship therapies. Emergent therapies include the use of intravenous tissue-type plasminogen activator and the reversal of coagulopathies. Although many of the care elements are similar to those of a Primary Stroke Center, compliance rates of ≥67% are suggested in recognition of the staffing, logistical, and financial challenges faced by rural facilities. ASRHs will form the foundation for acute stroke care in many settings. Recommended elements of an ASRH build on those proven to improve care and outcomes at Primary Stroke Centers. The ASRH will be a key component for patient care within an evolving stroke system of care.
    Stroke 11/2013; 44(12). DOI:10.1161/STROKEAHA.113.002285 · 6.02 Impact Factor
  • Robert L Ruff, Stephen Cannon
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    ABSTRACT: Science is an exploration of knowledge. Early world maps did not recognize large land masses until someone first observed them. The report by Auré et al.(1) describes new territory in the field of periodic paralysis and other disorders of skeletal muscle membrane excitability. The muscle membrane has to balance on a knife edge between excessive excitability manifest by conditions such as myotonia, and inexcitability, as occurs intermittently in periodic paralysis.(2-4) Understanding disorders of altered muscle membrane excitability is important because the knowledge gained leads to increased understanding of how excitable membranes function and may suggest ways of treating membrane disorders that can involve many tissues, including brain, peripheral nerve, and skeletal and cardiac muscle.
    Neurology 10/2013; 81(21). DOI:10.1212/01.wnl.0000436072.13783.78 · 8.30 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. DOI:10.4088/JCP.12011nr2c · 5.14 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. DOI:10.1111/head.12123 · 3.19 Impact Factor
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    The Journal of Clinical Psychiatry 02/2013; 74(2):180-8. DOI:10.4088/JCP.12011co1c · 5.14 Impact Factor
  • Annals of the New York Academy of Sciences 12/2012; 1274(1):vii-viii. DOI:10.1111/j.1749-6632.2012.06835.x · 4.31 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. DOI:10.1111/j.1749-6632.2012.06841.x · 4.31 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. DOI:10.1682/JRRD.2011.12.0251 · 1.69 Impact Factor
  • Annals of the New York Academy of Sciences 12/2012; 1275(1):vii-viii. DOI:10.1111/nyas.12013 · 4.31 Impact Factor
  • Robert L Ruff, Ronald G Riechers
    JAMA The Journal of the American Medical Association 11/2012; 308(19):2032-3. DOI:10.1001/jama.2012.14008 · 30.39 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. DOI:10.1212/WNL.0b013e31825b5bee · 8.30 Impact Factor
  • Neurology 04/2012; 78(Meeting Abstracts 1):S49.003-S49.003. DOI:10.1212/WNL.78.1_MeetingAbstracts.S49.003 · 8.30 Impact Factor
  • Neurology 04/2012; 78(Meeting Abstracts 1):S49.001-S49.001. DOI:10.1212/WNL.78.1_MeetingAbstracts.S49.001 · 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 03/2012; 2(2):e000312. DOI:10.1136/bmjopen-2011-000312 · 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. DOI:10.1002/mus.22177 · 2.31 Impact Factor
  • Article: Reply.
    Henry J Kaminski, Gary Cutter, Robert L Ruff
    Muscle & Nerve 12/2011; 44(6):1001. DOI:10.1002/mus.22237 · 2.31 Impact Factor
  • Neurology 10/2011; 77(17):e101-2; author reply e103-4. · 8.30 Impact Factor

Publication Stats

2k Citations
566.53 Total Impact Points

Institutions

  • 1986–2015
    • Case Western Reserve University School of Medicine
      • • Department of Neurosciences
      • • Department of Neurology
      Cleveland, Ohio, United States
  • 2002–2014
    • Louis Stokes Cleveland VA Medical Center
      Cleveland, Ohio, United States
  • 2013
    • University of Texas Southwestern Medical Center
      • Department of Neurology and Neurotherapeutics
      Dallas, Texas, United States
  • 1991–2013
    • Case Western Reserve University
      • • Louis Stokes Cleveland Veterans Administration Medical Center
      • • Department of Neurology (University Hospitals Case Medical Center)
      Cleveland, Ohio, United States
  • 1982–1984
    • University of Washington Seattle
      • Department of Physiology and Biophysics
      Seattle, WA, United States