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Ingram EO, Karr JE. The Sport Concussion Assessment Tool: A multidimensional symptom model for detecting elevated post-concussion symptoms. Clin Neuropsychol 2024; 38:1683-1706. [PMID: 38369485 PMCID: PMC11330539 DOI: 10.1080/13854046.2024.2315735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 12/20/2023] [Indexed: 02/20/2024]
Abstract
Objective: Investigate whether a four-factor model of post-concussion symptoms (i.e. cognitive, physical, affective, and sleep-arousal) aids in identifying student-athletes with persistent concerns not reflected by a total symptom score. Method: Collegiate student-athletes (N = 32,066) from the Concussion Assessment Research and Education consortium completed the Sport Concussion Assessment Tool, 3rd edition Symptom Evaluation at baseline and two post-injury follow-ups (i.e. beginning RTP and 6-month). Confirmatory factor analysis was used to compare a one- and four-factor model of post-concussion symptoms. Normative reference data were compared across stratifications (e.g. sex, prior concussions, and number of pre-existing conditions) using Mann-Whitney U tests, and elevation rates (i.e. ≥ 84th percentile) for subscales and the total score were recorded. Results: The four-factor model fit well before and after injury (CFIs > .95). Greater symptom severity on the subscale and total scores was associated with female sex (ps<.001, r range: .07 to .14) and more pre-existing conditions (ps<.001, η 2 range: .01 to .04), while having more prior concussions was only related to total symptom scores (ps<.001, η 2<.01). After a concussion, a sizeable portion of student-athletes (i.e., RTP = 11.8%; 6-month = 8.3%) had subscale elevations despite no total score elevation. Physical subscale elevations at RTP were the most common (i.e., 11.9%), driven by head and neck pain. Conclusion: After a sport-related concussion, a four-factor symptom model can be used to assess persistent symptoms in collegiate student-athletes. Identifying athletes with domain-specific elevations may help clinicians identify areas for further assessment and, in some cases, personalized rehabilitation plans.
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Affiliation(s)
- Eric O Ingram
- Department of Psychology, University of Kentucky, Lexington, Kentucky, USA
| | - Justin E Karr
- Department of Psychology, University of Kentucky, Lexington, Kentucky, USA
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da Silva Fiorin F, do Espírito Santo CC, Da Silva JT, Chung MK. Inflammation, brain connectivity, and neuromodulation in post-traumatic headache. Brain Behav Immun Health 2024; 35:100723. [PMID: 38292321 PMCID: PMC10827408 DOI: 10.1016/j.bbih.2024.100723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 01/03/2024] [Accepted: 01/05/2024] [Indexed: 02/01/2024] Open
Abstract
Post-traumatic headache (PTH) is a debilitating condition that affects individuals with different levels of traumatic brain injury (TBI) severity. The difficulties in developing an effective treatment are related to a lack of understanding the complicated mechanisms and neurobiological changes in brain function after a brain injury. Preclinical studies have indicated that peripheral and central sensitization of the trigeminal nociceptive pathways contributes to PTH. While recent brain imaging studies have uncovered widespread changes in brain functional connectivity following trauma, understanding exactly how these networks contribute to PTH after injury remains unknown. Stimulation of peripheral (trigeminal or vagus) nerves show promising efficacies in PTH experimental animals, likely mediated by influencing TBI-induced pathological plasticity by decreasing neuroinflammation and neuronal apoptosis. Non-invasive brain stimulations, such as transcranial magnetic or direct current stimulations, show analgesia for multiple chronic pain conditions, including PTH. Better mechanistic understanding of analgesia achieved by neuromodulations can define peripheral and central mechanisms involved in the development, the resolution, and the management of PTH.
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Affiliation(s)
- Fernando da Silva Fiorin
- Department of Neural and Pain Sciences, School of Dentistry, University of Maryland Baltimore, Program in Neuroscience, Center to Advance Chronic Pain Research, Baltimore, MD, USA
| | - Caroline Cunha do Espírito Santo
- Graduate Program in Neuroengineering, Edmond and Lily Safra International Institute of Neuroscience, Santos Dumont Institute, Brazil
| | - Joyce T. Da Silva
- Department of Neural and Pain Sciences, School of Dentistry, University of Maryland Baltimore, Program in Neuroscience, Center to Advance Chronic Pain Research, Baltimore, MD, USA
| | - Man-Kyo Chung
- Department of Neural and Pain Sciences, School of Dentistry, University of Maryland Baltimore, Program in Neuroscience, Center to Advance Chronic Pain Research, Baltimore, MD, USA
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Underreporting of Traumatic Brain Injuries in Pediatric Craniomaxillofacial Trauma: A 20-Year Retrospective Cohort Study. Plast Reconstr Surg 2023; 151:105e-114e. [PMID: 36251865 DOI: 10.1097/prs.0000000000009783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Despite clinical concerns associated with pediatric traumatic brain injuries (TBIs), they remain grossly underreported. This is the first retrospective study to characterize concomitant pediatric TBIs and craniomaxillofacial (CMF) trauma patients, including frequency, presentation, documentation, and outcomes. METHODS An institutional review board-approved retrospective cohort study was performed to identify all pediatric patients presenting with CMF fractures at a high-volume, tertiary trauma center between the years 1990 and 2010. Patient charts were reviewed for demographic information, presentation, operative management, length of stay, mortality at 2 years, dentition, CMF fracture patterns, and concomitant TBIs. Data were analyzed using two-tailed t tests and chi-square analysis. A value of P≤ 0.05 was considered statistically significant. RESULTS Of the 2966 pediatric CMF trauma patients identified and included for analysis [mean age, 7 ± 4.7 years; predominantly White (59.8%), and predominantly male (64.0%)], 809 had concomitant TBI (frequency, 27.3%). Only 1.6% of the TBI cases were documented in charts. Mortality at 2 years, length of stay in the hospital, and time to follow-up increased significantly from mild to severe TBIs. Concomitant TBIs were more common with skull and upper third fractures than CMF trauma without TBIs (81.8% versus 61.1%; P < 0.05). CONCLUSIONS Concomitant TBIs were present in a significant number of pediatric CMF trauma cases but were not documented for most cases. CMF surgeons should survey all pediatric CMF trauma patients for TBI and manage with neurology and/or neurosurgery teams. Future prospective studies are necessary to characterize and generate practice-guiding recommendations. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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Terry DP, Büttner F, Huebschmann NA, Gardner AJ, Cook NE, Iverson GL. Systematic Review of Pre-injury Migraines as a Vulnerability Factor for Worse Outcome Following Sport-Related Concussion. Front Neurol 2022; 13:915357. [PMID: 35795801 PMCID: PMC9251462 DOI: 10.3389/fneur.2022.915357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 05/23/2022] [Indexed: 11/13/2022] Open
Abstract
Background Individuals with migraine disorders may be affected differently by concussions compared to individuals without migraine disorders. Prior studies on this topic have had mixed results. The purpose of this study was to systematically examine clinical outcomes following a sport-related concussion in athletes who have a pre-injury history of migraines. Methods All studies published prior to 15 May 2021 that examined pre-injury migraines as a possible predictor of clinical recovery from concussion were included. The search included (i) sport/athlete-related terms, (ii) concussion-related terms, and (iii) diverse predictor/modifier terms. After removing duplicates, 5,118 abstracts were screened, 538 full-text articles were reviewed, and 27 articles were included for narrative synthesis without meta-analysis (n = 25 with unique samples). Risk of bias was assessed using the domain-based Quality In Prognosis Studies (QUIPS) tool. Results Most studies did not find pre-injury migraines to be associated with concussion outcome, but several of these studies had small or very small sample sizes, as well as other methodological weaknesses. Risk of bias varied greatly across studies. Some of the larger, better-designed studies suggested pre-injury migraines may be a risk factor for worse concussion outcome. Most articles examined pre-injury migraines as an exploratory/secondary predictor of concussion outcome; very few were designed to examine migraine as the primary focus of the study. Migraine history was predominantly based on self-report and studies included minimal information about migraine (e.g., age of onset, frequency/severity, past treatment). Effect sizes were usually not reported or able to be calculated from reported study data. Conclusion There is some evidence to suggest that pre-injury migraines may be a vulnerability factor for a worse outcome following concussion, with studies having the lowest risk of bias reporting a positive association. Future studies should focus on improving methodological quality when assessing the relationship between pre-injury migraines and concussion outcome and better characterizing pre-injury migraine status. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019128292, identifier: PROSPERO 2019 CRD42019128292.
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Affiliation(s)
- Douglas P. Terry
- Vanderbilt Sports Concussion Center, Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Fionn Büttner
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
| | | | - Andrew J. Gardner
- Priority Research Center for Stroke and Brain Injury, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | - Nathan E. Cook
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, United States
- MassGeneral Hospital for Children Sports Concussion Program, Boston, MA, United States
| | - Grant L. Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, United States
- MassGeneral Hospital for Children Sports Concussion Program, Boston, MA, United States
- Department of Physical Medicine and Rehabilitation, Spaulding Research Institute, Charlestown, MA, United States
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5
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Blumenfeld A, McVige J, Knievel K. Post-traumatic headache: Pathophysiology and management - A review. JOURNAL OF CONCUSSION 2022. [DOI: 10.1177/20597002221093478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Post-traumatic headache (PTH) is a common secondary headache due to traumatic brain injury. In the past, significant research has been conducted to understand the pathophysiology and treatment options for PTH. However, PTH still lacks evidence-based treatment, and most of the management depends on the primary phenotype observed in the patient. Objective The main objective of this review is to provide a single reference that covers the current understanding of the pathophysiology and the treatment options available for PTH. Methods A detailed literature search on PubMed was performed, and a narrative review was prepared. Results The pathophysiology of PTH is multifactorial. Acute PTH may be attributed to increased peripheral pain sensitization with impaired pain inhibiting pathways. Chronic or persistent PTH may be due to a chronic inflammatory response and peripheral as well as central sensitization. The mechanism responsible for the transition of acute to persistent PTH is unknown. The migraine-like phenotype is reported to be the most prevalent headache type seen in PTH. New targets for preventive treatment have been identified in recent years, such as neuropeptides like calcitonin-gene-related peptide (CGRP), nitric oxide, and glutamate. The preventive pharmacological and non-pharmacological strategies employed for migraine (e.g. anti-CGRP monoclonal antibodies, onabotulinumtoxinA, physical therapy, cognitive and behavioral treatment, and neurostimulation techniques) have shown in preliminary studies that they are potentially efficacious, but large, randomized, double blind, placebo controlled trials are needed to further establish these as treatment options for PTH. Conclusions The lack of evidence-based treatment for PTH has created a need for future large trials to confirm the safety and efficacy of the currently employed treatments.
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Affiliation(s)
- Andrew Blumenfeld
- The Los Angeles Headache Center and The San Diego Headache Center, Los Angeles, CA, USA
| | | | - Kerry Knievel
- Barrow Neurological Institute, Phoenix, Arizona, USA
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Effects of Cognitive Behavioral Therapy on Pain and Sleep in Adults with Traumatic Brain Injury: A Systematic Review and Meta-Analysis. Neural Plast 2021; 2021:6552246. [PMID: 34804154 PMCID: PMC8601855 DOI: 10.1155/2021/6552246] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/29/2021] [Accepted: 09/27/2021] [Indexed: 11/23/2022] Open
Abstract
The objective of this study was to systematically review the literature on the effects of cognitive behavioral therapy (CBT) on insomnia and pain in patients with traumatic brain injury (TBI). PubMed, Embase, the Cochrane Library, Cumulative Index to Nursing and Allied Health, and Web of Science databases were searched. Outcomes, including pain, sleep quality, and adverse events, were investigated. Differences were expressed using mean differences (MDs) with 95% confidence intervals (CIs). The statistical analysis was performed using STATA 16.0. Twelve trials with 476 TBI patients were included. The included studies did not indicate a positive effect of CBT on pain. Significant improvements were shown for self-reported sleep quality, reported with the Pittsburgh Self-Reported Sleep Quality Index (MD, -2.30; 95% CI, -3.45 to -1.15; P < 0.001) and Insomnia Severity Index (MD, -5.12; 95% CI, -9.69 to -0.55; P = 0.028). No major adverse events related to CBT were reported. The underpowered evidence suggested that CBT is effective in the management of sleep quality and pain in TBI adults. Future studies with larger samples are recommended to determine significance. This trial is registered with PROSPERO registration number CRD42019147266.
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Starosta AJ, Adams RS, Marwitz JH, Kreutzer J, Monden KR, Dams O'Connor K, Hoffman J. Scoping Review of Opioid Use After Traumatic Brain Injury. J Head Trauma Rehabil 2021; 36:310-327. [PMID: 34489382 PMCID: PMC8428300 DOI: 10.1097/htr.0000000000000721] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To summarize the current literature to identify what research has been conducted, examine the approaches used, and determine what is presently known about prescription and nonprescription opioid receipts and use among individuals with traumatic brain injury (TBI). DATA SOURCES The search strategy included the following: opioid; opiate; analgesics, opioid; opiate alkaloids; or opioid-related disorders; AND brain injury; brain injuries; brain injuries, traumatic; head injury; head injuries; head injuries, closed; head injuries, penetrating; brain concussion; diffuse axonal injury; diffuse axonal injuries; brain trauma/s; head trauma/s; concussion; craniocerebral trauma/s; or TBI. Filters included English and Adults (19+ years). Study Selection: Inclusion: English language, adults with stable TBI, and prescription opioid receipt or use after TBI. Exclusion: Animal models, populations with other acquired brain injury, acute TBI management, and non-peer-reviewed articles, theses, or conference abstracts. Multiple reviewers screened abstracts and full-text articles for eligibility. In total, 771 abstracts were screened, 183 full texts were reviewed, and 21 met eligibility criteria. Data Extraction: Relevant content was independently extracted by multiple observers, including authors, design, sample identification and data source/s, TBI severity, TBI assessment, opioid assessment, study population (demographics, N), military affiliation, comparison groups, date of data collection, and summary of findings. RESULTS Studies were published between 1987 and 2019; most data were collected prior to 2015. The majority utilized administrative and electronic medical record data from the Department of Veterans Affairs and retrospective cohort designs, and most focused on prescription opioids. There were no studies evaluating interventions to reduce use of opioids in TBI populations. Preliminary findings suggest that prescription opioid receipt is strongly related to psychological symptoms, including comorbid depression, anxiety, and posttraumatic stress disorder. CONCLUSIONS Despite increased awareness of opioid receipt and use following TBI, there is limited investigation on the examination of this issue. Future studies should include more varied patient populations as well as evaluate interventions to reduce opioid use following TBI.
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Affiliation(s)
- Amy J Starosta
- Division of Rehabilitation Psychology, Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle (Drs Starosta and Hoffman); Institute for Behavioral Health at the Heller School for Social Policy & Management, Brandeis University, Waltham, Massachusetts (Dr Adams); Rocky Mountain Mental Illness Research Education and Clinical Center, Veterans Health Administration, Aurora, Colorado (Dr Adams); Division of Rehabilitation Psychology and Neuropsychology (Dr Kreutzer), Department of Physical Medicine and Rehabilitation (Ms Marwitz), Department of Rehabilitation Medicine, University of Minnesota, Minneapolis (Dr Monden); Brain Injury Research Center of Mount Sinai, Departments of Rehabilitation Medicine and Neurology, Icahn School of Medicine at Mount Sinai, New York City, New York (Dr Dams O'Connor)
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Lambrinakos-Raymond K, Dubrovsky AS, Gagnon I, Zemek R, Burstein B. Management of Pediatric Post-Concussion Headaches: National Survey of Abortive Therapies Used in the Emergency Department. J Neurotrauma 2021; 39:144-150. [PMID: 33787343 DOI: 10.1089/neu.2020.7508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Children frequently present to an Emergency Department (ED) after concussion, and headache is the most commonly associated symptom. Recent guidelines emphasize the importance of analgesia for post-concussion headache (PCH), yet evidence to inform treatment is lacking. We sought to characterize abortive therapies used to manage refractory PCH in the pediatric ED and factors associated with treatment. A scenario-based survey was distributed to ED physicians at all 15 Canadian tertiary pediatric centers. Participants were asked questions regarding ED treatment of acute (48 h) and persistent (1 month) PCH refractory to appropriate doses of acetaminophen/ibuprofen. Logistic regression was used to assess factors associated with treatment. Response rate was 63% (137/219). Nearly all physicians (128/137, 93%) endorsed treatment in the ED for acute PCH of severe intensity, with most selecting intravenous treatments (116/137, 84.7%). Treatments were similar for acute and persistent PCH. The most common treatments were metoclopramide (72%), physiologic saline (47%), and nonsteroidal anti-inflammatory agents (NSAIDS; 35%). Second-line ED treatments were more variable. For acute PCH of moderate intensity, overall treatment was lower (102/137, 74%; p < 0.0001), and NSAIDS (48%) were most frequently selected. In multi-variable regression analyses, no physician- or ED-level factor was associated with receiving treatment, or treatment using metoclopramide specifically. Treatment for refractory PCH in the pediatric ED is highly variable. Importantly, patients with severe PCH are most likely to receive intravenous therapies, often with metoclopramide, despite a paucity of evidence supporting these choices. Further research is urgently needed to establish the comparative effectiveness of pharmacotherapeutic treatments for children with refractory PCH.
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Affiliation(s)
- Kristen Lambrinakos-Raymond
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada.,UP Centre for Pediatric Emergencies, Brossard, Quebec, Canada
| | - Alexander Sasha Dubrovsky
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada.,UP Centre for Pediatric Emergencies, Brossard, Quebec, Canada
| | - Isabelle Gagnon
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada.,School of Physical and Occupational Therapy, McGill University, Montreal, Quebec, Canada
| | - Roger Zemek
- Departments of Pediatrics and Emergency Medicine and Research Institute, Children's Hospital of Eastern Ontario and University of Ottawa, Ottawa, Ontario, Canada
| | - Brett Burstein
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
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Varner C, Thompson C, de Wit K, Borgundvaag B, Houston R, McLeod S. Predictors of persistent concussion symptoms in adults with acute mild traumatic brain injury presenting to the emergency department. CAN J EMERG MED 2021; 23:365-373. [PMID: 33555602 DOI: 10.1007/s43678-020-00076-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 12/23/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To identify risk factors associated with persistent concussion symptoms in adults presenting to the emergency department (ED) with acute mild traumatic brain injury (TBI). METHODS This was a secondary analysis of a randomized controlled trial conducted in three Canadian EDs whereby the intervention had no impact on recovery or healthcare utilization outcomes. Adult (18-64 years) patients with a mild TBI sustained within the preceding 48 h were eligible for enrollment. The primary outcome was the presence of persistent concussion symptoms at 30 days, defined as the presence of ≥ 3 symptoms on the Rivermead Post-concussion Symptoms Questionnaire. RESULTS Of the 241 patients who completed follow-up, median (IQR) age was 33 (25 to 50) years, and 147 (61.0%) were female. At 30 days, 49 (20.3%) had persistent concussion symptoms. Using multivariable logistic regression, headache at ED presentation (OR: 7.7; 95% CI 1.6 to 37.8), being under the influence of drugs or alcohol at the time of injury (OR: 5.9; 95% CI 1.8 to 19.4), the injury occurring via bike or motor vehicle collision (OR: 2.9; 95% CI 1.3 to 6.0), history of anxiety or depression (OR: 2.4; 95% CI 1.2 to 4.9), and numbness or tingling at ED presentation (OR: 2.4; 95% CI 1.1 to 5.2), were found to be independently associated with persistent concussion symptoms at 30 days. CONCLUSIONS Five variables were found to be significant predictors of persistent concussion symptoms. Although mild TBI is mostly a self-limited condition, patients with these risk factors should be considered high risk for developing persistent concussion symptoms and flagged for early outpatient follow-up.
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Affiliation(s)
- Catherine Varner
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada. .,Schwartz/Reisman Emergency Medicine Institute, Toronto, ON, Canada. .,Department of Family and Community Medicine, University of Toronto, 206-600 University Avenue, Toronto, ON, M5G 1X5, Canada. .,Sinai Health System, Toronto, ON, Canada.
| | - Cameron Thompson
- Schwartz/Reisman Emergency Medicine Institute, Toronto, ON, Canada.,Sinai Health System, Toronto, ON, Canada
| | - Kerstin de Wit
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Bjug Borgundvaag
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Schwartz/Reisman Emergency Medicine Institute, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, 206-600 University Avenue, Toronto, ON, M5G 1X5, Canada.,Sinai Health System, Toronto, ON, Canada
| | - Reaves Houston
- Schwartz/Reisman Emergency Medicine Institute, Toronto, ON, Canada
| | - Shelley McLeod
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Schwartz/Reisman Emergency Medicine Institute, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, 206-600 University Avenue, Toronto, ON, M5G 1X5, Canada.,Sinai Health System, Toronto, ON, Canada
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10
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Remigio-Baker RA, Kiser S, Ferdosi H, Gregory E, Engel S, Sebesta S, Beauchamp D, Malik S, Scher A, Hinds SR. Provider Training in the Management of Headache Following Concussion Clinical Recommendation: Promoting a Standardized Means for Efficient Patient Recovery and Timely Return to Duty. Front Neurol 2020; 11:559311. [PMID: 33178105 PMCID: PMC7593659 DOI: 10.3389/fneur.2020.559311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 08/26/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Headache is a common symptom reported following concussion/mild traumatic brain injury. The Department of Defense's clinical recommendation (CR) describes guidance for primary care providers for the management of post-traumatic headache (PTH) in Service members. Objective: The objective of this study is to examine the association between training on the CR with provider clinical practice, patient behaviors, and symptom recovery. Methods: Participants were healthcare providers and two patient groups (one receiving care as usual [CAU] and another receiving care after provider training on PTH CR [CR+]). Providers were interviewed at three time points: (1) prior to CAU enrollment; (2) after CAU enrollment, but prior to training; and (3) after CR+ follow-up. Data from the second and third provider interview were used to evaluate a potential difference between provider practices pre- and post-training (n = 13). Patients were enrolled within 6 months of concussion. Patient outcomes (including neurobehavioral and headache symptoms) were assessed at three time-points: within 72 h (n = 35), at 1-week (n = 34) and at 1-month post-enrollment (n = 27). Results: Most follow-up care reported by providers were recommended within 72 h of initial visit post-training vs. >1 week pre-training. Additionally, providers reported a greater number of visits based on patient symptoms after training than before. Post-training, most providers reported referring patients to higher level of care “as needed,” if not “very rarely,” compared to 25% reported referrals prior to training. At 1-week post-enrollment the CR+ patient group reported more frequent medical provider visits compared to the CAU group. This trend was reversed at the 1-month follow-up whereby more CAU reported seeing a medical provider compared to CR+. By 1-week post-enrollment, fewer patients in the CR+ group reported being referred to any other providers or specialists compared to the CAU group. No differences in patient outcomes by provider training was found. Conclusion: The study results demonstrate the feasibility of training on the Management of Headache Following Concussion CR in order to change provider practices by promoting timely care, and promoting patient compliance as shown through improvement in follow-up visits and more monitoring within the primary care clinic.
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Affiliation(s)
- Rosemay A Remigio-Baker
- Defense and Veterans Brain Injury Center, Silver Spring, MD, United States.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States.,Naval Hospital Camp Pendleton, Camp Pendleton, CA, United States
| | - Seth Kiser
- Defense and Veterans Brain Injury Center, Silver Spring, MD, United States.,General Dynamics Information Technology, Falls Church, VA, United States
| | - Hamid Ferdosi
- Defense and Veterans Brain Injury Center, Silver Spring, MD, United States.,General Dynamics Information Technology, Falls Church, VA, United States
| | - Emma Gregory
- Defense and Veterans Brain Injury Center, Silver Spring, MD, United States
| | - Scot Engel
- Fort Hood Intrepid Spirit Center, Fort Hood, TX, United States
| | - Sean Sebesta
- Fort Bliss Intrepid Spirit Center, Fort Bliss, TX, United States
| | - Daniel Beauchamp
- Fort Bliss Intrepid Spirit Center, Fort Bliss, TX, United States
| | - Saafan Malik
- Defense and Veterans Brain Injury Center, Silver Spring, MD, United States
| | - Ann Scher
- Uniformed Services University, Bethesda, MD, United States
| | - Sidney R Hinds
- Uniformed Services University, Bethesda, MD, United States
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Ruiter KI, Boshra R, DeMatteo C, Noseworthy M, Connolly JF. Neurophysiological markers of cognitive deficits and recovery in concussed adolescents. Brain Res 2020; 1746:146998. [PMID: 32574566 DOI: 10.1016/j.brainres.2020.146998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 05/29/2020] [Accepted: 06/16/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The present study sought to determine: 1) whether concussed adolescents exhibited deficits in neurocognitive functioning as reflected by neurophysiological alterations; 2) if neurophysiological alterations could be linked to supplementary data such as the number of previous concussions and days since injury; and 3) if deficits in psychological health and behavioural tests increased during diagnosis duration. METHODS Twenty-six concussed adolescents were compared to twenty-eight healthy controls with no prior concussions. Self-report inventories evaluated depressive and concussive symptomatology, while behavioral tests evaluated cognitive ability qualitatively. To assess neurophysiological markers of cognitive function, two separate auditory oddball tasks were employed: 1) an active oddball task measuring executive control and attention as reflected by the N2b and P300, respectively; and 2) a passive oddball task assessing the early, automatic pre-conscious awareness processes as reflected by the MMN. RESULTS Concussed adolescents displayed delayed N2b and attenuated P300 responses relative to controls; showed elevated levels of depressive and concussive symptomatology; scored average-to- low-average in behavioral tests; and exhibited N2b response latencies that correlated with number of days since injury. CONCLUSION These findings demonstrate that concussed adolescents exhibit clear deficiencies in neurocognitive function, and that N2b response latency may be a marker of concussion recovery.
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Affiliation(s)
- Kyle I Ruiter
- McMaster University - ARiEAL Research Centre, L.R. Wilson Hall, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4M2, Canada; McMaster University - Department of Linguistics and Languages, Canada.
| | - Rober Boshra
- McMaster University - ARiEAL Research Centre, L.R. Wilson Hall, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4M2, Canada; McMaster University - School of Biomedical Engineering, McMaster University, ETB-406, 1280 Main St., West, Hamilton, ON L8S 4K1, Canada; MaRS Centre - Vector Institute, Canada.
| | - Carol DeMatteo
- McMaster University - School of Rehabilitation Sciences, Faculty of Health Sciences, McMaster University, Institute of Applied Health Sciences, Room 403, 1400 Main St. W., Hamilton, ON L8S 1C7, Canada.
| | - Michael Noseworthy
- McMaster University - School of Biomedical Engineering, McMaster University, ETB-406, 1280 Main St., West, Hamilton, ON L8S 4K1, Canada.
| | - John F Connolly
- McMaster University - ARiEAL Research Centre, L.R. Wilson Hall, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4M2, Canada; McMaster University - Department of Linguistics and Languages, Canada; McMaster University - School of Biomedical Engineering, McMaster University, ETB-406, 1280 Main St., West, Hamilton, ON L8S 4K1, Canada; McMaster University - Department of Psychology, Neuroscience and Behaviour, Canada; MaRS Centre - Vector Institute, Canada.
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12
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da Silva Fiorin F, do Espírito Santo CC, do Nascimento RS, Cassol G, Plácido E, Santos ARS, Marques JLB, Brocardo PS, Fighera MR, Royes LFF. Capsaicin-sensitive fibers mediate periorbital allodynia and activation of inflammatory cells after traumatic brain injury in rats: Involvement of TRPV1 channels in post-traumatic headache. Neuropharmacology 2020; 176:108215. [PMID: 32574651 DOI: 10.1016/j.neuropharm.2020.108215] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 05/30/2020] [Accepted: 06/15/2020] [Indexed: 12/26/2022]
Abstract
Post-traumatic headache (PTH) is a condition that frequently affects individuals after traumatic brain injury (TBI). Inflammation is one of the major causes of this disability. However, little is known about the trigger for, and endurance of, this painful process. Thus, the involvement of fibers containing the transient receptor potential vanilloid 1 (TRPV1) channels on the PTH and inflammation after TBI through neonatal treatment with capsaicin are investigated. Fluid percussion injury (FPI) in adult male Wistar rats caused periorbital allodynia in one, three and seven days after injury, and the neonatal treatment reversed the painful sensation in seven days. The lack of TRPV1 channels reduced the activation of macrophages and glial cells induced by TBI in the trigeminal system, which were characterized by glial fibrillary acidic protein (GFAP) and ionized calcium binding adapter molecule-1 (IBA-1) immune content in the ipsilateral trigeminal ganglion, brainstem, and perilesional cortex. Immunofluorescence analyses of the ipsilateral Sp5C nucleus demonstrated a hypertrophic astrocytes profile after TBI which was reduced with treatment. Moreover, effects of succinate sumatriptan (SUMA - 1 mg/kg), TRPV1 selective antagonist capsazepine (CPZ - 2 mg/kg), and TRP non-selective antagonist ruthenium red (RR - 3 mg/kg) were evaluated. Although all mentioned drugs reduced the painful sensation, SUMA and CPZ demonstrated a stronger effect compared to the RR treatment, reinforcing the involvement of TRPV1 channels in periorbital allodynia after TBI. Hence, this report suggests that TRPV1-containing fibers and TRPV1 channels are able to induce inflammation of the trigeminal system and maintain the painful sensation after TBI.
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Affiliation(s)
- Fernando da Silva Fiorin
- Programa de Pós-Graduação em Neurociências, Centro de Ciências Biológicas, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil; Laboratório de Neurobiologia da Dor e Inflamação, Departamento de Ciências Fisiológicas, Centro de Ciências Biológicas, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil; Laboratório de Bioquímica do Exercício, Universidade Federal de Santa Maria, Santa Maria, RS, Brazil.
| | - Caroline Cunha do Espírito Santo
- Programa de Pós-Graduação em Neurociências, Centro de Ciências Biológicas, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil; Laboratório de Neurobiologia da Dor e Inflamação, Departamento de Ciências Fisiológicas, Centro de Ciências Biológicas, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Raphael Santos do Nascimento
- Instituto de Engenharia Biomédica, Departamento de Engenharia Elétrica e Eletrônica, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Gustavo Cassol
- Laboratório de Bioquímica do Exercício, Universidade Federal de Santa Maria, Santa Maria, RS, Brazil
| | - Evelini Plácido
- Programa de Pós-Graduação em Neurociências, Centro de Ciências Biológicas, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil; Laboratório de Neuroplasticidade, Departamento de Ciências Morfológicas, Centro de Ciências Biológicas, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Adair Roberto Soares Santos
- Programa de Pós-Graduação em Neurociências, Centro de Ciências Biológicas, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil; Laboratório de Neurobiologia da Dor e Inflamação, Departamento de Ciências Fisiológicas, Centro de Ciências Biológicas, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Jefferson Luiz Brum Marques
- Instituto de Engenharia Biomédica, Departamento de Engenharia Elétrica e Eletrônica, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Patricia S Brocardo
- Programa de Pós-Graduação em Neurociências, Centro de Ciências Biológicas, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil; Laboratório de Neuroplasticidade, Departamento de Ciências Morfológicas, Centro de Ciências Biológicas, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Michele Rechia Fighera
- Programa de Pós-Graduação em Neurociências, Centro de Ciências Biológicas, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil; Laboratório de Bioquímica do Exercício, Universidade Federal de Santa Maria, Santa Maria, RS, Brazil
| | - Luiz Fernando Freire Royes
- Programa de Pós-Graduação em Neurociências, Centro de Ciências Biológicas, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil; Laboratório de Bioquímica do Exercício, Universidade Federal de Santa Maria, Santa Maria, RS, Brazil
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VanderEnde J, Bateman EA, MacKenzie HM, Sequeira K. Use of CGRP receptor blocker erenumab in the management of post-traumatic headache: a case series of 5 women. Brain Inj 2020; 34:1431-1434. [PMID: 32790533 DOI: 10.1080/02699052.2020.1807052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
CONTEXT Post-traumatic headache (PTH) is a disabling headache disorder and the most common sequela of mild traumatic brain injury. The pathophysiology of PTH is poorly understood and there is limited available evidence to guide prophylactic medication selection. Emerging understanding of the pathophysiology of migraine headaches has led to the development of monoclonal antibodies, including erenumab. Erenumab has shown promise for the prevention of primary migraine headache; however, it has not yet been studied in PTH. CASE SERIES five women (average age 43.0 ± 17.9y) received treatment with erenumab for PTH secondary to mTBI. The average duration of PTH prior to starting erenumab was 32.0 ± 18.2 months. All patients were taking at least one daily headache prophylactic therapy prior to erenumab. The average pre-erenumab headache intensity was 86/100. On erenumab, the average reported reduction in headache intensity was 51.1%. After starting erenumab, all five patients were able to discontinue one or more medication(s). The most common side effect was constipation (three patients). There were no serious adverse events after an average follow-up of 3.4 ± 1.5 months. One patient discontinued erenumab during this period of follow-up after the resolution of her headaches. CONCLUSION Erenumab appears to be safe and effective for the management of PTH.
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Affiliation(s)
- Jordan VanderEnde
- Department of Physical Medicine & Rehabilitation, Western University , London, Canada
| | - Emma A Bateman
- Department of Physical Medicine & Rehabilitation, Western University , London, Canada
| | - Heather M MacKenzie
- Department of Physical Medicine & Rehabilitation, Western University , London, Canada
| | - Keith Sequeira
- Department of Physical Medicine & Rehabilitation, Western University , London, Canada
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14
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Kim K, Priefer R. Evaluation of current post-concussion protocols. Biomed Pharmacother 2020; 129:110406. [PMID: 32768934 DOI: 10.1016/j.biopha.2020.110406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 06/10/2020] [Accepted: 06/14/2020] [Indexed: 10/23/2022] Open
Abstract
The growing number of concussions and mild traumatic brain injuries (mTBI) with the lack of evidence-based treatment options is a continuous health concern. This creates problems when evaluating and providing efficacious symptom management to patients suffering from post-concussion syndrome (PCS). Numerous pharmacological and non-pharmacological agents have been utilized in an attempt to treat PCS. Some of these approaches include physical therapy, analgesics, antidepressants, and nutraceuticals. Although these treatments have had some success, there has been inconsistent outcomes, with some examples of patients' symptoms worsening. Among pharmaceutical agents, fluoxetine has been a popular choice for the symptom management of PCS. Although some patients have had symptom resolution with the use of fluoxetine, there is still a lack of conclusive data. Of the several biochemical changes that occur in a patient's brain following a concussion, an increase in reactive oxygen species (ROS) is of particular concern. In order to counteract the responses of the brain, antioxidants, such as ascorbic acid, have been utilized to reverse the damaging cellular effects. However, this may inadvertently cause an increase in ROS, rather than a reduction. Although there is a lack of consistency in exactly when each treatment was used in the post-injury interval, it is important that we analyze the strengths and weaknesses of the most commonly used agents due to the lack of a set protocol. The studies were chosen in a non-exhaustive manner and were not consistent in patients' post-injury intervals, in addition to other baseline characteristics. However, over-arching claims that some treatments may benefit more than others can be made. This review evaluates both the pharmaceutical and non-pharmaceutical protocols that are most commonly utilized in post-concussive patients for their efficacy in treatment of post-concussive syndrome (PCS).
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Affiliation(s)
- Kristin Kim
- Massachusetts College of Pharmacy and Health Sciences University, Boston, MA, United States
| | - Ronny Priefer
- Massachusetts College of Pharmacy and Health Sciences University, Boston, MA, United States.
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Remigio-Baker RA, Kiser S, Ferdosi H, Gregory E, Engel S, Sebesta S, Beauchamp D, Malik S, Scher AI, Hinds SR. Current patterns of primary care provider practices for the treatment of post-traumatic headache in active duty military settings. PLoS One 2020; 15:e0236762. [PMID: 32706834 PMCID: PMC7380628 DOI: 10.1371/journal.pone.0236762] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 07/11/2020] [Indexed: 11/18/2022] Open
Abstract
Objective To provide a preliminary assessment of the current clinical practice for the treatment of post-traumatic headache following concussion in military primary health care settings. Background Headache is one of the most common symptoms post-concussion; however, little is known of the current clinical practices of primary care providers (on the treatment of post-traumatic headache), particularly in military settings. Methods Study participants were primary care providers (n = 65) who treated active duty Service members suffering from post-traumatic headache at two military installations. Qualitative data gathered via semi-structured interviews were used to describe provider practices and experience in treating patients with post-traumatic headache. Results Some patterns of care across primary care providers treating post-traumatic headache were consistent with the Department of Defense-recommended clinical recommendation (e.g., recommendation of both pharmacological and non-pharmacological treatment [89.4%]; engaging in follow-up care [100%]). Differences existed in timing of follow-up from initial visit [16.9% reporting within 24 hours; 21.5% reporting within 48–72 hours; and 26.2% reporting more than 1 week], the factors contributing to the type of care given (e.g., symptomatology [33.0%], injury characteristic [24.2%], patient characteristic [13.2%]) and the need for referral to higher level of care (e.g., symptomatology [44.6%], treatment failure [25.0%]). These variations may be indicative of individualized treatment which would be compliant with best clinical practice. Conclusion The results of this study demonstrate the current clinical practice in military primary care settings for the treatment of post-traumatic headache which can potentially inform and improve implementation of provider training and education.
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Affiliation(s)
- Rosemay A. Remigio-Baker
- Defense and Veterans Brain Injury Center, Silver Spring, MD, United States of America
- Henry Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States of America
- Naval Hospital Camp Pendleton, Camp Pendleton, CA, United States of America
- * E-mail:
| | - Seth Kiser
- Defense and Veterans Brain Injury Center, Silver Spring, MD, United States of America
- General Dynamics Information Technology, Falls Church, VA, United States of America
| | - Hamid Ferdosi
- Defense and Veterans Brain Injury Center, Silver Spring, MD, United States of America
- General Dynamics Information Technology, Falls Church, VA, United States of America
| | - Emma Gregory
- Defense and Veterans Brain Injury Center, Silver Spring, MD, United States of America
| | - Scot Engel
- Fort Hood, Intrepid Spirit Center, Ft Hood, TX, United States of America
| | - Sean Sebesta
- Fort Bliss, Intrepid Spirit Center, Ft Bliss, TX, United States of America
| | - Daniel Beauchamp
- Fort Bliss, Intrepid Spirit Center, Ft Bliss, TX, United States of America
| | - Saafan Malik
- Defense and Veterans Brain Injury Center, Silver Spring, MD, United States of America
| | - Ann I. Scher
- Preventive Medicine & Biostatistics, Uniformed Services University, Bethesda, MD, United States of America
| | - Sidney R. Hinds
- Neurology, Uniformed Services University, Bethesda, MD, United States of America
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Terry DP, Wojtowicz M, Cook NE, Maxwell BA, Zafonte R, Seifert T, Silverberg ND, Berkner PD, Iverson GL. Factors Associated With Self-Reported Concussion History in Middle School Athletes. Clin J Sport Med 2020; 30 Suppl 1:S69-S74. [PMID: 32132480 DOI: 10.1097/jsm.0000000000000594] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Identifying personal characteristics associated with sustaining a concussion is of great interest, yet only a few have examined this in children. The purpose of this study was to examine the association between sex, neurodevelopmental disorders, health history, and lifetime history of self-reported concussion in 12- and 13-year-old athletes. DESIGN Cross-sectional study. SETTING Middle schools. PARTICIPANTS Participants were 1744 twelve- and thirteen-year-old student athletes who completed preseason Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) testing, including a self-report questionnaire about previous concussions, developmental diagnoses, and previous medical treatment. INDEPENDENT VARIABLES Age, sex, attention-deficit/hyperactivity disorder (ADHD), learning disabilities (LDs), and previous treatment for migraine. MAIN OUTCOME MEASURES Self-reported history of concussion. RESULTS A minority of athletes (13.7%) reported previous concussions (1 concussion, n = 181; 2 concussions, n = 41; and 3+ concussions, n = 17). A small proportion reported a history of ADHD (4.4%), LD (2.8%) or migraine treatment (4.0%). Higher rates of self-reported previous concussions were associated with male sex [16.9% vs 9.1%; χ(1) = 21.47, P < 0.001] and previous migraine treatment [31.9% vs 13.0%; χ(1) = 20.08, P < 0.001]. There were no differences in self-reported concussion history between 12- and 13-year olds (P = 0.18) and those with/without ADHD (P = 0.41) or LDs (P = 0.06). The overall logistic regression model was statistically significant [χ(5) = 42.01, P < 0.001] but explained only 4.3% of the variance. Previous treatment for migraine [P < 0.001, Exp(B) = 3.30] and male sex [P < 0.001, Exp(B) = 2.06] were independently associated with a self-reported concussion history, whereas age, LD, and ADHD were not (P's > 0.05). CONCLUSIONS Male sex and previous migraine treatment were associated with higher rates of self-reported previous concussions in both independent and multivariate models in middle school athletes, whereas age, ADHD, and LDs were not.
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Affiliation(s)
- Douglas P Terry
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
- Spaulding Rehabilitation Hospital, Boston, Massachusetts
- Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, Massachusetts
- MassGeneral Hospital for Children Sport Concussion Program, Boston, Massachusetts
| | | | - Nathan E Cook
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
- Spaulding Rehabilitation Hospital, Boston, Massachusetts
- MassGeneral Hospital for Children Sport Concussion Program, Boston, Massachusetts
| | - Bruce A Maxwell
- Department of Computer Science, Colby College, Waterville, Maine
| | - Ross Zafonte
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
- Spaulding Rehabilitation Hospital, Boston, Massachusetts
- Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, Massachusetts
- MassGeneral Hospital for Children Sport Concussion Program, Boston, Massachusetts
| | - Tad Seifert
- Departments of Neurology and Sports Health, Norton Healthcare, Louisville, Kentucky
- Kentucky Boxing and Wrestling Commission, Frankfort, Kentucky
| | - Noah D Silverberg
- Division of Physical Medicine & Rehabilitation, University of British Columbia, Vancouver, BC, Canada
- Vancouver Coastal Health Research Institute Rehabilitation Research Program, Vancouver, BC, Canada; and
| | - Paul D Berkner
- Department of Biology and Health Services, Colby College, Waterville, Maine
| | - Grant L Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
- Spaulding Rehabilitation Hospital, Boston, Massachusetts
- Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, Massachusetts
- MassGeneral Hospital for Children Sport Concussion Program, Boston, Massachusetts
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17
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Scott BR, Uomoto JM, Barry ES. Impact of Pre-Existing Migraine and Other Co-Morbid or Co-Occurring Conditions on Presentation and Clinical Course Following Deployment-Related Concussion. Headache 2020; 60:526-541. [PMID: 31898813 DOI: 10.1111/head.13709] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To describe the clinical presentation and early clinical course of a sample of deployed U.S. military service members following concussion, underscoring the impact of pre-existing migraine and other co-occurring conditions. It is important to obtain a comprehensive clinical history to identify evidence of underlying migraine and other health conditions which may contribute to an individual's presenting symptoms influencing early management and outcomes following concussion. Early outcome measures assessed include headache treatment response and fitness for return to duty. BACKGROUND Acute concussion is reported to result in an array of somatic, cognitive, and behavioral symptoms. It is well established that these symptoms are not specific for concussion and may result from exacerbation of pre-existing or underlying medical conditions and factors. Although most symptoms attributable to concussion resolve within days to weeks, there is evidence that persistent symptoms beyond that specific recovery time may be attributable to factors other than concussion. Military populations are at risk for a number of recognized co-morbid and co-occurring conditions, as well as special situational and psychosocial factors which may influence symptoms and clinical course following concussion. In addition, combat-related concussion frequently occurs in the setting of a blast or military vehicle accidents thus causing concurrent injuries where musculoskeletal injuries may contribute to the clinical presentation. The resultant acute stress reaction, secondary to the traumatic experience associated with concussion, may also cause or aggravate underlying psychological co-morbidities that may influence presenting symptoms. Prior studies identified co-morbidities associated with chronic post-concussive syndrome, which we find are also present during the early phase following deployment-related concussion, thereby influencing presentation and impacting recovery. This retrospective chart review was intended to demonstrate the presence and potential impact of co-morbid and co-occurring conditions contributing to symptoms following concussion, especially migraine due to its high prevalence among post-traumatic headaches. METHODS Retrospective chart review was performed by the treating neurologist of 40 service members following concussion in the deployed environment. Clinical symptoms and co-morbid and co-occurring conditions including evidence of pre-existing migraine identified during comprehensive neurologic evaluations were collected. Both pre-deployment/pre-traumatic and post-traumatic headache features supporting migraine and early instituted headache management and treatment response are described. Rates of return to duty in this sample were also tabulated. RESULTS Headaches were the most frequently reported acute symptom following concussion in this deployed service member population (38/40 patients [98%]), followed by insomnia, tinnitus, impaired concentration, nausea, dizziness, anxiety, impaired balance, depression, and hearing loss. Co-occurring acute injuries, acute stress reaction, and recent onset medication overuse were the most frequent co-occurring conditions identified by the treating neurologist as potentially contributing to the service member's presentation. Chronic co-morbidities identified included chronic headache, anxiety/depression, insomnia, and post-traumatic stress disorder. Service members with 3 or more identified co-morbidities or co-occurring conditions were more likely to require evacuation from theater. Pre-deployment headaches were reported by 25/40 [63%] service members, with 5/40 [12.5%] reporting known prior personal history of migraine. Of those reporting pre-deployment headaches, 21/25 [84%] described migraine features and/or triggers, though most [(15/25) 60%] reported as infrequent. Daily post-traumatic headaches were frequent (26/38 [68%]) and associated with typical migraine features and/or triggers. Of those treated with triptans (16/40 patient [42%]), most (12/16 patient [75%]) showed positive treatment response. CONCLUSIONS Concussion in the deployed settings does not occur in isolation, with co-morbid and co-occurring conditions being common. Presence of multiple co-morbidities appears to influence clinical course and overall recovery. Post-traumatic headaches are often phenotypically fully consistent with migraine, and appear related to pre-existing migraine if supported by detailed pre-deployment headache history suggesting same. Careful and comprehensive history taking and evaluation is invaluable in identifying associated conditions including migraine, potentially helping clinicians with more accurate symptom attribution, diagnoses, and improved clinical management following acute concussion.
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Affiliation(s)
- Beverly R Scott
- Traumatic Brain Injury Program, Madigan Army Medical Center, Joint Base Lewis-McChord, WA, USA
| | - Jay M Uomoto
- General Dynamics Health Solutions, Defense and Veterans Brain Injury Center, Joint Base Lewis-McChord, WA, USA
| | - Erin S Barry
- Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Abstract
Although concussion has been a subject of interest for centuries, this condition remains poorly understood. The mechanistic underpinnings and accepted definition of concussion remain elusive. To make sense of these issues, this article presents a brief history of concussion studies, detailing the evolution of motivations and experimental conclusions over time. Interest in concussion as a subject of scientific inquiry has increased with growing concern about the long-term consequences of mild traumatic brain injury (TBI). Although concussion is often associated with mild TBI, these conditions-the former a neurological syndrome, the latter a neurological event-are distinct, both mechanistically and pathobiologically. Modern research primarily focuses on the study of the biomechanics, pathophysiology, potential biomarkers and neuroimaging to distinguish concussion from mild TBI. In addition, mild TBI and concussion outcomes are influenced by age, sex, and genetic differences in people. With converging experimental objectives and methodologies, future concussion research has the potential to improve clinical assessment, treatment, and preventative measures.
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Abstract
Concussion is a public health crisis affecting vulnerable populations including youth athletes. As awareness increases, more patients with acute concussion are seeking medical evaluations. Internists are frontline medical providers and thus should be able to identify, diagnose, manage, and know when to refer patients with concussion. Management of concussion includes rapid removal from play, symptomatic treatment, and return to learn/play recommendations. Inappropriate management may lead to recurrent concussions, prolonged recovery, and potential long-term consequences. Understanding the key features of diagnosis, postinjury assessment tools, symptomatic treatment, and management of concussion, including return to learn/play recommendations, is essential for primary care providers.
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Affiliation(s)
- William T Jackson
- Department of Neurology, Mayo Clinic College of Medicine, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA
| | - Amaal J Starling
- Department of Neurology, Mayo Clinic College of Medicine, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA.
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20
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Baker VB, Eliasen KM, Hack NK. Lifestyle modifications as therapy for medication refractory post-traumatic headache (PTHA) in the military population of Okinawa. J Headache Pain 2018; 19:113. [PMID: 30466384 PMCID: PMC6755565 DOI: 10.1186/s10194-018-0943-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 11/04/2018] [Indexed: 12/17/2022] Open
Abstract
Objective Our aim was 1) to reduce disability, as characterized by headache frequency, duration and severity in patients with post-traumatic headache (PTHA), 2) to reduce the number of medical boards and work limitations in patients with post traumatic headache, and 3) to reduce use of medical resources and clinic visits related to headache or migraine. Background Modifiable risk factors for PTHA include stressful life event, sleep disturbances, and medication overuse. Cognitive-behavioral strategies, biofeedback, and relaxation therapy may have an important role in treatment and preventing progression to chronic post-traumatic headache (CPTHA). There is limited literature and a known practice gap for implementation of these techniques. Design/methods An IRB approved project focused on patients who were seen for PTHA and CPTHA. 1) Intervention consisted of lifestyle teaching, cognitive-behavioral therapy and biofeedback, supplemented by decreasing polypharmacy. 2) Patients were followed for 2 years and a retrospective review was conducted for 2 years prior to presentation. 3) Outcome measures included reduction in migraine intensity or frequency, improved quality of life, duty status, and decreased utilization of clinic visits. Results Over the course of one year, 221 patients were treated for migraines in the Naval Okinawa Neurology Clinic. Of these, 22 active duty service members and 3 Dependents suffered a mild TBI prior to onset. After intervention, there was a 36% decrease in PTHA frequency, 56% decrease in headache severity and 60% of patients had improved quality of life as compared to the 2 years prior to intervention. Twenty-four percent had reduction in polypharmacy. Appointment frequency for migraine decreased from an average of 6.8 to 2.6 per year. Conclusions An implemented program geared towards reducing polypharmacy was shown to improve safety, quality of life and reduce hospitalizations from the burden of migraines. Our systematic approach resulted in quality of life improvements and decreased use of medical resources. Trial registration Authors received the approval of NAVMED West, Okinawa Naval Hospital Institutional Review Board on January 13th, 2016. QI.2016.0021.
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Affiliation(s)
- Virginia B Baker
- Department of Neurology, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD, 20889, USA.
| | - Kathryn M Eliasen
- Department of Anesthesiology, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD, 20889, USA
| | - Nawaz K Hack
- Department of Neurology, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD, 20889, USA
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Kacperski J. Pharmacotherapy for Persistent Posttraumatic Headaches in Children and Adolescents: A Brief Review of the Literature. Paediatr Drugs 2018; 20:385-393. [PMID: 29876872 DOI: 10.1007/s40272-018-0299-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Concussion, now most often referred to as mild traumatic brain injury in recent literature, is common in pediatrics, and headache is often the most common complaint post-injury. Although most children and adolescents recover within 1-2 weeks, some develop frequent and debilitating headaches that can last for months or longer. Most clinicians would agree on the importance of managing both acute and persistent posttraumatic headaches appropriately to speed recovery, minimize disability, maximize function, and improve quality of life, but there are no well-established guidelines to instruct physicians in doing so. As this continues to be a developing field, there is much we still need to learn about concussion and the appropriate strategies to prevent and treat these injuries and their sequelae. This review is intended to help providers understand the current evidence, and sometimes the lack thereof, and ultimately to lead to improved care for children with headaches after mild traumatic brain injury.
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Affiliation(s)
- Joanne Kacperski
- Division of Neurology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2015, Cincinnati, OH, 45229-3039, USA. .,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.
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Elliott MB, Ward SJ, Abood ME, Tuma RF, Jallo JI. Understanding the endocannabinoid system as a modulator of the trigeminal pain response to concussion. Concussion 2018; 2:CNC49. [PMID: 30202590 PMCID: PMC6122691 DOI: 10.2217/cnc-2017-0010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 08/29/2017] [Indexed: 12/29/2022] Open
Abstract
Post-traumatic headache is the most common symptom of postconcussion syndrome and becomes a chronic neurological disorder in a substantial proportion of patients. This review provides a brief overview of the epidemiology of postconcussion headache, research models used to study this disorder, as well as the proposed mechanisms. An objective of this review is to enhance the understanding of how the endogenous cannabinoid system is essential for maintaining the balance of the CNS and regulating inflammation after injury, and in turn making the endocannabinoid system a potential modulator of the trigeminal response to concussion. The review describes the role of endocannabinoid modulation of pain and the potential for use of phytocannabinoids to treat pain, migraine and concussion.
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Affiliation(s)
- Melanie B Elliott
- Department of Neurosurgery, Vickie & Jack Farber Institute for Neuroscience Thomas Jefferson University, PA 19107, USA.,Department of Neurosurgery, Vickie & Jack Farber Institute for Neuroscience Thomas Jefferson University, PA 19107, USA
| | - Sara J Ward
- Department of Pharmacology, Lewis Katz School of Medicine, Temple University, PA 19140, USA.,Department of Pharmacology, Lewis Katz School of Medicine, Temple University, PA 19140, USA
| | - Mary E Abood
- Department of Anatomy & Cell Biology, Lewis Katz School of Medicine, Temple University, PA 19140, USA.,Department of Anatomy & Cell Biology, Lewis Katz School of Medicine, Temple University, PA 19140, USA
| | - Ronald F Tuma
- Department of Physiology Lewis Katz School of Medicine, Temple University, PA 19140, USA.,Department of Physiology Lewis Katz School of Medicine, Temple University, PA 19140, USA
| | - Jack I Jallo
- Department of Neurosurgery, Vickie & Jack Farber Institute for Neuroscience Thomas Jefferson University, PA 19107, USA.,Department of Neurosurgery, Vickie & Jack Farber Institute for Neuroscience Thomas Jefferson University, PA 19107, USA
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da Silva Fiorin F, do Espírito Santo CC, Santos ARS, Fighera MR, Royes LFF. Implication of surgical procedure in the induction of headache and generalized painful sensation in a fluid percussion injury model in rats. J Neurosci Methods 2018; 307:23-30. [DOI: 10.1016/j.jneumeth.2018.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 05/29/2018] [Accepted: 06/12/2018] [Indexed: 12/27/2022]
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Terry DP, Huebschmann NA, Maxwell BA, Cook NE, Mannix R, Zafonte R, Seifert T, Berkner PD, Iverson GL. Preinjury Migraine History as a Risk Factor for Prolonged Return to School and Sports following Concussion. J Neurotrauma 2018; 36:142-151. [PMID: 29732944 DOI: 10.1089/neu.2017.5443] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Having a preexisting migraine disorder might be a risk factor for a prolonged recovery following a sport-related concussion. We examined whether having a migraine history was associated with a prolonged return to academics and athletics following a concussion. High school and collegiate athletes (n = 1265; 42% female) who sustained a sport-related concussion were monitored by athletic trainers using a web-based surveillance system that collects information about concussion recovery. Nonparametric Kolmogorov-Smirnov tests (KS) were used to compare days to return to academics/athletics across groups due to non-normally distributed outcome variables and unequal distributions of scores between groups. Chi-squared tests were used to examine the proportion of players who had not returned to academics/athletics at 7, 14, and 21 days post-injury stratified by self-reported migraine history. There were 117 athletes (9.2%) who reported a preinjury migraine history. Athletes with a history of migraine took a median of 6 days to return to academics (mean [M] = 10.6, standard deviation [SD] = 14.2) and 15.5 days to return to athletics (M = 23.8, SD = 30.8), while those with no migraine history took a median of 5 days to return to academics (M = 7.5, SD = 10.9) and 14 days to return to athletics (M = 19.4, SD = 19.4). There were no statistically significant differences in days to return to school or athletics between the groups (KS p > 0.05). However, a lower percentage of athletes with a history of migraine had returned to school after 7 days (57% vs. 68%, χ2 = 5.53, p = 0.02), 14 days (75% vs. 88%, χ2 = 14.21, p < 0.001), and 21 days post-injury (89% vs. 94%, χ2 = 4.90, p = 0.03). Stratifying the analyses by sex showed that this effect was significant in girls and women with preexisting migraines, but not boys and men with preexisting migraines. There were no group differences in recovery rates when examining return to athletics. Athletes with a preinjury migraine history may be at an elevated risk for a protracted return to school after concussion, especially girls and women.
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Affiliation(s)
- Douglas P Terry
- 1 Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Brigham and Women's Hospital , Harvard Medical School, Boston Massachusetts
- 2 Home Base, A Red Sox Foundation and Massachusetts General Hospital Program , Boston, Massachusetts
- 3 MassGeneral Hospital for Children™ Sport Concussion Program , Charlestown, Massachusetts
| | | | - Bruce A Maxwell
- 5 Department of Computer Science, Colby College , Waterville, Maine
| | - Nathan E Cook
- 1 Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Brigham and Women's Hospital , Harvard Medical School, Boston Massachusetts
- 3 MassGeneral Hospital for Children™ Sport Concussion Program , Charlestown, Massachusetts
| | - Rebekah Mannix
- 6 Division of Emergency Medicine, Boston Children's Hospital, Brigham and Women's Hospital , Harvard Medical School, Boston Massachusetts
- 10 Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Ross Zafonte
- 1 Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Brigham and Women's Hospital , Harvard Medical School, Boston Massachusetts
- 2 Home Base, A Red Sox Foundation and Massachusetts General Hospital Program , Boston, Massachusetts
- 7 Department of Physical Medicine and Rehabilitation, Brigham and Women's Hospital , Harvard Medical School, Boston Massachusetts
| | - Tad Seifert
- 8 Sports Neurology Program, Norton Healthcare, Kentucky Boxing and Wrestling Commission , Louisville, Kentucky
| | - Paul D Berkner
- 9 Health Services and the Department of Biology, Colby College , Waterville, Maine
| | - Grant L Iverson
- 1 Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Brigham and Women's Hospital , Harvard Medical School, Boston Massachusetts
- 2 Home Base, A Red Sox Foundation and Massachusetts General Hospital Program , Boston, Massachusetts
- 3 MassGeneral Hospital for Children™ Sport Concussion Program , Charlestown, Massachusetts
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Mehalick ML, Glueck AC. Examining the relationship and clinical management between traumatic brain injury and pain in military and civilian populations. Brain Inj 2018; 32:1307-1314. [PMID: 29993307 DOI: 10.1080/02699052.2018.1495339] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
In this review, we discuss the comorbidity of traumatic brain injury (TBI) and pain among civilians and military members, the common causes of pain resulting from TBI, and offer insight about the therapeutic management of TBI symptoms and pain. Traumatic brain injury (TBI) is a debilitating health problem and one of the most common post-TBI symptoms is pain, which can contribute to psychological issues such as Post-traumatic stress disorder (PTSD) and depression. Headache pain appears to be the most common type of pain that results from TBI, yet pain can also be more widespread. Managing TBI symptoms and pain simultaneously is difficult because extensive randomized control and clinical studies assessing the effectiveness of therapeutic approaches are lacking. Pharmacological agents such as antidepressants and Triptans and nonpharmacological therapies such as cognitive rehabilitation and physical therapies are commonly used yet it is unknown how effective these therapies are in the long-term. A combination of pharmacological and non-pharmacological therapies is often more effective for managing TBI symptoms and pain than either treatment alone. However, future research is needed to determine the most therapeutic approaches for managing the comorbidity of pain and TBI symptoms in the long term. This review offers suggestions for such future studies.
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Affiliation(s)
- Melissa L Mehalick
- a Department of Neurotrauma, Operational and Undersea Medicine Directorate , Naval Medical Research Center , Silver Spring , MD, USA
| | - Amanda C Glueck
- b Sports Medicine Research Institute , University of Kentucky , Lexington , KY, USA
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Abstract
Patients with brain tumor exhibit wide-ranging prognoses and functional implications of their disease and treatments. In general, the supportive care needs of patients with brain tumor, including disabling effects, have been recognized to be high. This review (1) briefly summarizes brain tumor types, treatments, and prognostic information for the rehabilitation clinician; (2) reviews evidence for rehabilitation, including acute inpatient rehabilitation and cognitive rehabilitation, and the approaches to selected common symptom and medical management issues; and (3) examines emerging data about survivorship, such as employment, community integration, and fitness.
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Affiliation(s)
- Mary M Vargo
- Physical Medicine and Rehabilitation, MetroHealth Medical Center, Case Western Reserve University, 2500 MetroHealth Drive, Cleveland, OH 44109, USA.
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Kontos AP, Reches A, Elbin RJ, Dickman D, Laufer I, Geva AB, Shacham G, DeWolf R, Collins MW. Preliminary evidence of reduced brain network activation in patients with post-traumatic migraine following concussion. Brain Imaging Behav 2017; 10:594-603. [PMID: 26091725 DOI: 10.1007/s11682-015-9412-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Post-traumatic migraine (PTM) (i.e., headache, nausea, light and/or noise sensitivity) is an emerging risk factor for prolonged recovery following concussion. Concussions and migraine share similar pathophysiology characterized by specific ionic imbalances in the brain. Given these similarities, patients with PTM following concussion may exhibit distinct electrophysiological patterns, although researchers have yet to examine the electrophysiological brain activation in patients with PTM following concussion. A novel approach that may help differentiate brain activation in patients with and without PTM is brain network activation (BNA) analysis. BNA involves an algorithmic analysis applied to multichannel EEG-ERP data that provides a network map of cortical activity and quantitative data during specific tasks. A prospective, repeated measures design was used to evaluate BNA (during Go/NoGo task), EEG-ERP, cognitive performance, and concussion related symptoms at 1, 2, 3, and 4 weeks post-injury intervals among athletes with a medically diagnosed concussion with PTM (n = 15) and without (NO-PTM) (n = 22); and age, sex, and concussion history matched controls without concussion (CONTROL) (n = 20). Participants with PTM had significantly reduced BNA compared to NO-PTM and CONTROLS for Go and NoGo components at 3 weeks and for NoGo component at 4 weeks post-injury. The PTM group also demonstrated a more prominent deviation of network activity compared to the other two groups over a longer period of time. The composite BNA algorithm may be a more sensitive measure of electrophysiological change in the brain that can augment established cognitive assessment tools for detecting impairment in individuals with PTM.
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Affiliation(s)
- Anthony P Kontos
- Department of Orthopaedic Surgery/UPMC Sports Medicine Concussion Program, University of Pittsburgh, 3200 South Water St, Pittsburgh, PA, 15203, USA.
| | | | - R J Elbin
- Department of Health, Human Performance and Recreation/Office for Sport Concussion Research, University of Arkansas, Fayetteville, AR, 72701, USA
| | | | | | | | | | - Ryan DeWolf
- Department of Orthopaedic Surgery/UPMC Sports Medicine Concussion Program, University of Pittsburgh, 3200 South Water St, Pittsburgh, PA, 15203, USA
| | - Michael W Collins
- Department of Orthopaedic Surgery/UPMC Sports Medicine Concussion Program, University of Pittsburgh, 3200 South Water St, Pittsburgh, PA, 15203, USA
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Seifert T, Sufrinko A, Cowan R, Scott Black W, Watson D, Edwards B, Livingston S, Webster K, Akers D, Lively M, Kontos AP. Comprehensive Headache Experience in Collegiate Student-Athletes: An Initial Report From the NCAA Headache Task Force. Headache 2017; 57:877-886. [DOI: 10.1111/head.13104] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2017] [Indexed: 12/25/2022]
Affiliation(s)
| | | | | | - W. Scott Black
- Department of Family and Community Medicine; University of Kentucky
| | - Dave Watson
- Department of Neurology; West Virginia University
| | - Bill Edwards
- Department of Athletics; Western Kentucky University
| | | | | | - David Akers
- Department of Statistics; University of Kentucky
| | - Mathew Lively
- Department of Medicine and Pediatrics; West Virginia University
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Abstract
OBJECTIVE The purpose of this study was to investigate the association between migraine headache and concussion in athletes. DESIGN Case-control observational study. SETTING A university-associated combined sports neurology and orthopedic sports medicine clinic. PARTICIPANTS A total of 221 male (n = 140) and female (n = 81) athletes aged 12 to 24 years, including 115 concussion cases (52%) and 106 orthopedic controls (48%), were included in this study. INTERVENTIONS Participants completed a one-page questionnaire that recorded their age, sex, reason for visit (concussion vs any other injury), concussion history, and self/immediate family member migraine headache history. MAIN OUTCOME MEASURES The odds of having a previous history of migraine headache were compared in the concussion group versus orthopedic controls. RESULTS Controlling for between-group differences in age and sex, there was a significant positive association between concussion group status and history of migraine headache [adjusted odds ratio (OR), 1.90; 95% confidence interval (CI), 1.03-3.50. P = 0.039]. However, when including a previous concussion history in the statistical model, this relationship failed to reach significance [adjusted OR, 1.68; 95% CI, 0.89-3.16. P = 0.107]. CONCLUSIONS These results suggest that there is an association between migraine headache and concussion in athletes, but the cause-effect nature of this relationship cannot be determined. Migraine headache should be considered a modifying factor when caring for concussed athletes.
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Tyburski AL, Cheng L, Assari S, Darvish K, Elliott MB. Frequent mild head injury promotes trigeminal sensitivity concomitant with microglial proliferation, astrocytosis, and increased neuropeptide levels in the trigeminal pain system. J Headache Pain 2017; 18:16. [PMID: 28176234 PMCID: PMC5296267 DOI: 10.1186/s10194-017-0726-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 01/18/2017] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Frequent mild head injuries or concussion along with the presence of headache may contribute to the persistence of concussion symptoms. METHODS In this study, the acute effects of recovery between mild head injuries and the frequency of injuries on a headache behavior, trigeminal allodynia, was assessed using von Frey testing up to one week after injury, while histopathological changes in the trigeminal pain pathway were evaluated using western blot, ELISA and immunohistochemistry. RESULTS: A decreased recovery time combined with an increased mild closed head injury (CHI) frequency results in reduced trigeminal allodynia thresholds compared to controls. The repetitive CHI group with the highest injury frequency showed the greatest reduction in trigeminal thresholds along with greatest increased levels of calcitonin gene-related peptide (CGRP) in the trigeminal nucleus caudalis. Repetitive CHI resulted in astrogliosis in the central trigeminal system, increased GFAP protein levels in the sensory barrel cortex, and an increased number of microglia cells in the trigeminal nucleus caudalis. CONCLUSIONS Headache behavior in rats is dependent on the injury frequency and recovery interval between mild head injuries. A worsening of headache behavior after repetitive mild head injuries was concomitant with increases in CGRP levels, the presence of astrocytosis, and microglia proliferation in the central trigeminal pathway. Signaling between neurons and proliferating microglia in the trigeminal pain system may contribute to the initiation of acute headache after concussion or other traumatic brain injuries.
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Affiliation(s)
- Ashley L Tyburski
- Department of Neurosurgery, Thomas Jefferson University, 1020 Locust Street, Philadelphia, PA, 19107, USA
| | - Lan Cheng
- Department of Neurosurgery, Thomas Jefferson University, 1020 Locust Street, Philadelphia, PA, 19107, USA
| | | | | | - Melanie B Elliott
- Department of Neurosurgery, Thomas Jefferson University, 1020 Locust Street, Philadelphia, PA, 19107, USA.
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Goeke JM. Postconcussion Syndrome: Neuropsychological Evaluation and Management. Psychiatr Ann 2017. [DOI: 10.3928/00485713-20170106-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Predictors of Pharmacological Intervention in Adolescents With Protracted Symptoms After Sports-Related Concussion. PM R 2017; 9:847-855. [DOI: 10.1016/j.pmrj.2016.12.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 12/22/2016] [Accepted: 12/29/2016] [Indexed: 01/10/2023]
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Varner CE, McLeod S, Nahiddi N, Lougheed RE, Dear TE, Borgundvaag B. Cognitive Rest and Graduated Return to Usual Activities Versus Usual Care for Mild Traumatic Brain Injury: A Randomized Controlled Trial of Emergency Department Discharge Instructions. Acad Emerg Med 2017; 24:75-82. [PMID: 27792852 DOI: 10.1111/acem.13073] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 08/18/2016] [Accepted: 08/23/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVES It is estimated that 15%-25% of patients with a mild traumatic brain injury (MTBI) diagnosed in the emergency department (ED) will develop postconcussive syndrome. The objective of this study was to determine if patients randomized to graduated return to usual activity discharge instructions had a decrease in their Post-Concussion Symptom Score (PCSS) 2 weeks after MTBI compared to patients who received usual care MTBI discharge instructions. METHODS This was a pragmatic, randomized trial of adult (18-64 years) patients of an academic ED (annual census 60,000) diagnosed with MTBI occurring within 24 hours of ED visit. The intervention group received cognitive rest and graduated return to usual activity discharge instructions, and the control group received usual care discharge instructions that did not instruct cognitive rest or graduated return. Patients were contacted by text message or phone 2 and 4 weeks post-ED discharge and asked to complete the PCSS, a validated, 22-item questionnaire, to determine if there was a change in their symptoms. Secondary outcomes included change in PCSS at 4 weeks, number follow-up physician visits, and time off work/school. RESULTS A total of 118 patients were enrolled in the study (58 in the control group and 60 in the intervention). The mean (±SD) age was 35.2 (±13.7) years and 43 (36.4%) were male. There was no difference with respect to change in PCSS at 2 weeks (10.5 vs. 12.8; ∆2.3, 95% confidence interval [CI] = 7.0 to 11.7) and 4 weeks post-ED discharge (21.1 vs 18.3; ∆2.8, 95% CI = 6.9 to 12.7) for the intervention and control groups, respectively. The number of follow-up physician visits and time off work/school were similar when the groups were compared. Thirty-eight (42.2%) and 23 (30.3%) of patients in this cohort had ongoing MTBI symptoms (PCSS > 20) at 2 and 4 weeks, respectively. CONCLUSIONS Results from this study suggest graduated return to usual activity discharge instructions do not impact rate of resolution of MTBI symptoms 2 weeks after ED discharge. Given that patients continue to experience symptoms 2 and 4 weeks after MTBI, more investigation is needed to determine how best to counsel and treat patients with postconcussive symptoms.
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Affiliation(s)
- Catherine E. Varner
- Department of Family and Community Medicine University of Toronto Toronto Ontario
- Department of Emergency Medicine Mount Sinai Hospital Toronto Ontario Canada
- Schwartz/Reisman Emergency Medicine Institute Mount Sinai Hospital Toronto Ontario Canada
| | - Shelley McLeod
- Department of Family and Community Medicine University of Toronto Toronto Ontario
- Department of Emergency Medicine Mount Sinai Hospital Toronto Ontario Canada
- Schwartz/Reisman Emergency Medicine Institute Mount Sinai Hospital Toronto Ontario Canada
| | - Negine Nahiddi
- Department of Family and Community Medicine University of Toronto Toronto Ontario
| | - Rosamond E. Lougheed
- Department of Family and Community Medicine University of Toronto Toronto Ontario
| | - Taylor E. Dear
- Schwartz/Reisman Emergency Medicine Institute Mount Sinai Hospital Toronto Ontario Canada
| | - Bjug Borgundvaag
- Department of Family and Community Medicine University of Toronto Toronto Ontario
- Department of Emergency Medicine Mount Sinai Hospital Toronto Ontario Canada
- Schwartz/Reisman Emergency Medicine Institute Mount Sinai Hospital Toronto Ontario Canada
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Morin M, Langevin P, Fait P. Cervical Spine Involvement in Mild Traumatic Brain Injury: A Review. JOURNAL OF SPORTS MEDICINE (HINDAWI PUBLISHING CORPORATION) 2016; 2016:1590161. [PMID: 27529079 PMCID: PMC4977400 DOI: 10.1155/2016/1590161] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 05/30/2016] [Accepted: 06/19/2016] [Indexed: 06/06/2023]
Abstract
Background. There is a lack of scientific evidence in the literature on the involvement of the cervical spine in mTBI; however, its involvement is clinically accepted. Objective. This paper reviews evidence for the involvement of the cervical spine in mTBI symptoms, the mechanisms of injury, and the efficacy of therapy for cervical spine with concussion-related symptoms. Methods. A keyword search was conducted on PubMed, ICL, SportDiscus, PEDro, CINAHL, and Cochrane Library databases for articles published since 1990. The reference lists of articles meeting the criteria (original data articles, literature reviews, and clinical guidelines) were also searched in the same databases. Results. 4,854 records were screened and 43 articles were retained. Those articles were used to describe different subjects such as mTBI's signs and symptoms, mechanisms of injury, and treatments of the cervical spine. Conclusions. The hypothesis of cervical spine involvement in post-mTBI symptoms and in PCS (postconcussion syndrome) is supported by increasing evidence and is widely accepted clinically. For the management and treatment of mTBIs, few articles were available in the literature, and relevant studies showed interesting results about manual therapy and exercises as efficient tools for health care practitioners.
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Affiliation(s)
- Michael Morin
- Department of Human Kinetics, Université du Québec à Trois-Rivières (UQTR), Trois-Rivières, QC, Canada G9A 5H7
- Research Group on Neuromusculoskeletal Dysfunctions (GRAN), UQTR, Trois-Rivières, QC, Canada G9A 5H7
| | - Pierre Langevin
- Cortex Médecine et Réadaptation Concussion Clinic, Quebec City, QC, Canada G1W 0C5
- Department of Rehabilitation, Faculty of Medicine, Laval University, Quebec City, QC, Canada G1V 0A6
| | - Philippe Fait
- Department of Human Kinetics, Université du Québec à Trois-Rivières (UQTR), Trois-Rivières, QC, Canada G9A 5H7
- Research Group on Neuromusculoskeletal Dysfunctions (GRAN), UQTR, Trois-Rivières, QC, Canada G9A 5H7
- Cortex Médecine et Réadaptation Concussion Clinic, Quebec City, QC, Canada G1W 0C5
- Research Center in Neuropsychology and Cognition (CERNEC), Montreal, QC, Canada H3C 3J7
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Seifert T. Sports Neurology in Clinical Practice: Case Studies. Neurol Clin 2016; 34:733-46. [PMID: 27445251 DOI: 10.1016/j.ncl.2016.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
With regard to persistent posttraumatic headache, there is legitimate concern that duration of symptoms may have an impact on the efficacy of future treatment attempts. Without neuropathologic confirmation, a clinical diagnosis of chronic traumatic encephalopathy cannot be made with a high degree of confidence. Sport-related headaches are challenging in a return-to-play context, because it is often unclear whether an athlete has an exacerbation of a primary headache disorder, has new-onset headache unrelated to trauma, or is in the recovery phase after concussion. Regular physical exercise may prove beneficial to multiple neurologic disease states.
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Affiliation(s)
- Tad Seifert
- Sports Concussion Program, Norton Healthcare, NCAA Headache Task Force, 3991 Dutchmans Lane, Suite 310, Louisville, KY 40207, USA.
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38
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Xu H, Pi H, Ma L, Su X, Wang J. Incidence of Headache After Traumatic Brain Injury in China: A Large Prospective Study. World Neurosurg 2016; 88:289-296. [DOI: 10.1016/j.wneu.2015.12.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 12/02/2015] [Accepted: 12/03/2015] [Indexed: 01/03/2023]
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Abstract
It is time to stop using the term concussion as it has no clear definition and no pathological meaning. This confusion is increasingly problematic as the management of ‘concussed’ individuals is a pressing concern. Historically, it has been used to describe patients briefly disabled following a head injury, with the assumption that this was due to a transient disorder of brain function without long-term sequelae. However, the symptoms of concussion are highly variable in duration, and can persist for many years with no reliable early predictors of outcome. Using vague terminology for post-traumatic problems leads to misconceptions and biases in the diagnostic process, producing uninterpretable science, poor clinical guidelines and confused policy. We propose that the term concussion should be avoided. Instead neurologists and other healthcare professionals should classify the severity of traumatic brain injury and then attempt to precisely diagnose the underlying cause of post-traumatic symptoms.
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Affiliation(s)
- David J Sharp
- Computational, Cognitive, and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital Campus, London, UK
| | - Peter O Jenkins
- Computational, Cognitive, and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital Campus, London, UK
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Hoffer ME, Szczupak M, Kiderman A, Crawford J, Murphy S, Marshall K, Pelusso C, Balaban C. Neurosensory Symptom Complexes after Acute Mild Traumatic Brain Injury. PLoS One 2016; 11:e0146039. [PMID: 26727256 PMCID: PMC4699767 DOI: 10.1371/journal.pone.0146039] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 12/11/2015] [Indexed: 12/02/2022] Open
Abstract
Mild Traumatic Brain Injury (mTBI) is a prominent public health issue. To date, subjective symptom complaints primarily dictate diagnostic and treatment approaches. As such, the description and qualification of these symptoms in the mTBI patient population is of great value. This manuscript describes the symptoms of mTBI patients as compared to controls in a larger study designed to examine the use of vestibular testing to diagnose mTBI. Five symptom clusters were identified: Post-Traumatic Headache/Migraine, Nausea, Emotional/Affective, Fatigue/Malaise, and Dizziness/Mild Cognitive Impairment. Our analysis indicates that individuals with mTBI have headache, dizziness, and cognitive dysfunction far out of proportion to those without mTBI. In addition, sleep disorders and emotional issues were significantly more common amongst mTBI patients than non-injured individuals. A simple set of questions inquiring about dizziness, headache, and cognitive issues may provide diagnostic accuracy. The consideration of other symptoms may be critical for providing prognostic value and treatment for best short-term outcomes or prevention of long-term complications.
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Affiliation(s)
- Michael E. Hoffer
- Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, Florida, United States of America
- University of Miami Sports Performance and Wellness Institute, Miami, Florida, United States of America
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, United States of America
- * E-mail:
| | - Mikhaylo Szczupak
- Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, Florida, United States of America
- University of Miami Sports Performance and Wellness Institute, Miami, Florida, United States of America
| | | | - James Crawford
- Department of Otolaryngology, Madigan Army Medical Center, Tacoma, Washington, United States of America
| | - Sara Murphy
- Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, Florida, United States of America
| | - Kathryn Marshall
- Department of Otolaryngology, Madigan Army Medical Center, Tacoma, Washington, United States of America
| | - Constanza Pelusso
- Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, Florida, United States of America
- University of Miami Sports Performance and Wellness Institute, Miami, Florida, United States of America
| | - Carey Balaban
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania United States of America
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Abstract
Disabling sequelae occur in a majority of patients diagnosed with brain tumor, including glioma, such as cognitive deficits, weakness, and visual perceptual changes. Often, multiple impairments are present concurrently. Healthcare staff must be aware of the "biographic disruption" the patient with glioma has experienced. While prognostic considerations factor into rehabilitation goals and expectations, regardless of prognosis the treatment team must offer cohesive support, facilitating hope, function, and quality of life. Awareness of family and caregiver concerns plays an important role in the overall care. Inpatient rehabilitation, especially after surgical resection, has been shown to result in functional improvement and homegoing rates on a par with individuals with other neurologic conditions, such as stroke or traumatic brain injury. Community integration comprises a significant element of life satisfaction, as has been shown in childhood glioma survivors. Employment is often affected by the glioma diagnosis, but may be ameliorated, when appropriate, by addressing modifiable factors such as depression, fatigue, or sleep disturbance, or by workplace accommodations. Further research is needed into many facets of rehabilitation in the setting of glioma, including establishing better care models for consistently identifying and addressing functional limitations in this population, measuring outcomes of various levels of rehabilitation care, identifying optimal physical activity strategies, delineating the long-term effects of rehabilitation interventions, and exploring impact of rehabilitation interventions on caregiver burden. The effective elements of cognitive rehabilitation, including transition of cognitive strategies to everyday living, need to be better defined.
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Affiliation(s)
- Mary Vargo
- Department of Physical Medicine and Rehabilitation, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH, USA.
| | | | - Pär Salander
- Department of Social Work, Umeå University, Umeå, Sweden
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Kacperski J, Arthur T. Management of post-traumatic headaches in children and adolescents. Headache 2015; 56:36-48. [DOI: 10.1111/head.12737] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2015] [Indexed: 01/03/2023]
Affiliation(s)
- Joanne Kacperski
- Division of Neurology; Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
| | - Todd Arthur
- Department of Pediatrics, College of Medicine; University of Cincinnati; Cincinnati OH USA
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Junn C, Bell KR, Shenouda C, Hoffman JM. Symptoms of Concussion and Comorbid Disorders. Curr Pain Headache Rep 2015; 19:46. [DOI: 10.1007/s11916-015-0519-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Detecting Migraine in Patients with Mild Traumatic Brain Injury Using Three Different Headache Measures. Behav Neurol 2015; 2015:693925. [PMID: 26106255 PMCID: PMC4461723 DOI: 10.1155/2015/693925] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 05/04/2015] [Accepted: 05/13/2015] [Indexed: 11/17/2022] Open
Abstract
Posttraumatic migraine may represent an important subtype of headache among the traumatic brain injury (TBI) population and is associated with increased recovery times. However, it is underdiagnosed in patients with mild traumatic brain injury (mTBI). This study examined the effectiveness of the self-administered Nine-Item Screener (Nine-Item Screener-SA), the Headache Impact Test- 6 (HIT-6), the 3-Item Migraine Screener, and the Rivermead Post-Concussion Questionnaire (RPQ) at discriminating between mTBI patients with (n = 23) and without (n = 20) migraines. The Nine-Item Screener demonstrated significant differences between migraine patients with and without migraine on nearly every question, especially on Question 9 (disability), sensitivity: 0.95 and specificity: 0.65 (95% CI, 0.64–0.90). The HIT-6 demonstrated significant differences between migraine and no-migraine patients on disability and pain severity, with disability having a sensitivity of 0.70 and specificity of 0.75 (95% CI, 0.54–0.83). Only Question 3 of the 3-Item ID Migraine Screener (photosensitivity) showed significant differences between migraine and no-migraine patients, sensitivity: 0.84 and specificity: 0.55 (CI, 0.52–0.82). The RPQ did not reveal greater symptoms in migraine patients compared with those without. Among headache measures, the Nine-Item Screener-SA best differentiated between mTBI patients with and without migraine. Disability may best identify migraine sufferers among the TBI population.
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Intravenous migraine therapy in children with posttraumatic headache in the ED. Am J Emerg Med 2015; 33:635-9. [PMID: 25676851 DOI: 10.1016/j.ajem.2015.01.053] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 01/28/2015] [Accepted: 01/29/2015] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND More than 3.8 million children sustain traumatic brain injuries annually. Treatment of posttraumatic headache (PTH) in the emergency department (ED) is variable, and benefits are unclear. OBJECTIVE The objective of the study is to determine if intravenous migraine therapy reduces pain scores in children with PTH and factors associated with improved response. METHODS This was a retrospective study of children, 8 to 21 years old, presenting to a tertiary pediatric ED with mild traumatic brain injury (mTBI) and PTH from November 2009 to June 2013. Inclusion criteria were mTBI (defined by diagnosis codes) within 14 days of ED visit, headache, and administration of one or more intravenous medications: ketorolac, prochlorperazine, metoclopramide, chlorpromazine, and ondansetron. Primary outcome was treatment success defined by greater than or equal to 50% pain score reduction during ED visit. Bivariate analysis and logistic regression were used to determine predictors of treatment success: age, sex, migraine or mTBI history, time since injury, ED head computed tomographic (CT) imaging, and pretreatment with oral analgesics. RESULTS A total of 254 patients were included. Mean age was 13.8 years, 51% were female, 80% were white, mean time since injury was 2 days, and 114 patients had negative head CTs. Eighty-six percent of patients had treatment success with 52% experiencing complete resolution of headache. Bivariate analysis showed that patients who had a head CT were less likely to respond (80% vs 91%; P = .008). CONCLUSIONS Intravenous migraine therapy reduces PTH pain scores for children presenting within 14 days after mTBI. Further prospective work is needed to determine long-term benefits of acute PTH treatment in the ED.
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Yerry JA, Kuehn D, Finkel AG. Onabotulinum Toxin A for the Treatment of Headache in Service Members With a History of Mild Traumatic Brain Injury: A Cohort Study. Headache 2015; 55:395-406. [DOI: 10.1111/head.12495] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2014] [Indexed: 01/03/2023]
Affiliation(s)
- Juanita A. Yerry
- Department of Brain Injury Medicine; Womack Army Medical Center (WAMC); Ft. Bragg NC USA
| | - Devon Kuehn
- Department of Brain Injury Medicine; Womack Army Medical Center (WAMC); Ft. Bragg NC USA
| | - Alan G. Finkel
- Department of Brain Injury Medicine; Womack Army Medical Center (WAMC); Ft. Bragg NC USA
- Defense and Veterans Brain Injury Center; Silver Spring MD USA
- Carolina Headache Institute; Chapel Hill NC USA
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Kjeldgaard D, Forchhammer HB, Teasdale TW, Jensen RH. Cognitive behavioural treatment for the chronic post-traumatic headache patient: a randomized controlled trial. J Headache Pain 2014; 15:81. [PMID: 25441170 PMCID: PMC4266545 DOI: 10.1186/1129-2377-15-81] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 11/21/2014] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Chronic post-traumatic headache (CPTH) after mild head injury can be difficult to manage. Research is scarce and successful interventions are lacking.To evaluate the effect of a group-based Cognitive Behavioural Therapy (CBT) intervention in relation to headache, pain perception, psychological symptoms and quality of life in patients with CPTH. METHODS Ninety patients with CPTH according to ICHD-2 criteria were enrolled from the Danish Headache Center into a randomized, controlled trial. Patients were randomly assigned to either a waiting list group or to a nine-week CBT group intervention. At baseline and after 26 weeks all patients completed the Rivermead Post Concussion Symptoms Questionnaire, SF-36, SCL-90-R and a headache diary. RESULTS The CBT had no effect on headache and pressure pain thresholds and only a minor impact on the CPTH patients' quality of life, psychological distress, and the overall experience of symptoms. The waiting-list group experienced no change in headache but, opposed to the treatment group, a significant decrease in somatic and cognitive symptoms indicating a spontaneous remission over time. CONCLUSIONS Our primarily negative findings confirm that management of patients with CPTH still remains a considerable challenge. Psychological group therapy with CBT might be effective in an earlier stage of CPTH and in less severely affected patients but our findings strongly underline the need for randomized controlled studies to test the efficacy of psychological therapy.
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Affiliation(s)
- Dorte Kjeldgaard
- Danish Headache Center, Department of Neurology, Glostrup Hospital, University of Copenhagen, Copenhagen, DK, Denmark
| | - Hysse B Forchhammer
- Department of Neurology, Glostrup Hospital, University of Copenhagen, Copenhagen, DK, Denmark
| | - Thomas W Teasdale
- The Department of Psychology, Faculty of Social Sciences, University of Copenhagen, Copenhagen, DK, Denmark
| | - Rigmor H Jensen
- Danish Headache Center, Department of Neurology, Glostrup Hospital, University of Copenhagen, Nordre Ringvej 69, DK-2600 Glostrup, Copenhagen, DK, Denmark
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DiTommaso C, Hoffman JM, Lucas S, Dikmen S, Temkin N, Bell KR. Medication usage patterns for headache treatment after mild traumatic brain injury. Headache 2014; 54:511-9. [PMID: 24741687 DOI: 10.1111/head.12254] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To describe patient self-report of headache treatment in the first year following mild traumatic brain injury (TBI). BACKGROUND An understanding of appropriate management of symptoms after mild TBI is crucial for improving acute care and long-term outcomes. This is particularly true for post-traumatic headaches as recent studies suggest that headaches after mild TBI are common with multiple phenotypes. In addition, symptoms such as headache after mild TBI are often managed by primary care providers without specialty training, and often in medically underserved areas. Outside of previous opinion papers, few studies have guided the treatment or examined the effectiveness of the interventions for post-traumatic headache. METHODS One hundred sixty-seven participants admitted to a level 1 trauma hospital with mild TBI who were prospectively enrolled and reported new or worse headache at 3, 6, or 12 months after injury. RESULTS Participants were primarily male (75%), white (75%), injured in vehicle crashes (62%), and had completed high school (83%). The majority of headaches met International Classification of Headache Disorders-2nd edition criteria for migraine/probable migraine, followed by tension-type headache. Despite the diverse nature of headaches, more than 70% of those with headache at each time period used acetaminophen or a nonsteroidal anti-inflammatory drug for headache control. Only 8% of those with the migraine/probable migraine phenotype used triptans. Of those individuals who used medication, 26% of those with migraine/probable migraine phenotype and 70% of those with tension headache phenotype endorsed complete relief (vs partial or no relief) because of medication use. The majority of individuals with tension headache reported never taking medication. CONCLUSIONS Headaches after mild TBI are frequent and are not optimally treated. Results suggest that many individuals with mild TBI may be self-treating their headaches by utilizing over-the-counter pain relief medications. These medications, however, are only providing effective treatment for a minority of this population. Further research must be conducted to develop evidence-guided treatment and educate providers.
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