Persistent problems 1 year after mild traumatic brain injury: a longitudinal population study in New Zealand

Facilitators of and barriers to return to work after mild traumatic brain injury: A thematic analysis

Individuals with mild traumatic brain injury (mTBI) may experience protracted symptoms affecting their ability to work. Several actors may facilitate or act as a barrier to a successful return to work (RTW). This qualitative study used semi-structured in-depth interviews with 22 adults with mTBI at 2-5 years post injury, targeting experiences of how different actors facilitated or acted as a barrier in the RTW process, and encompassed the mTBI trajectory from the acute phase to the post-acute phase. A thematic analysis with a hermeneutical phenomenological approach was used to analyse data. Three main themes emerged. (1) Worker-employer relationship: Workplace accommodations such as decreased working hours, modified working conditions, and support from co-workers were lacking. (2) The role of the general practitioner: The general practitioner was lacking treatment and referral opportunities and failed to provide the patient with relevant and individualized guidance. (3) Municipal case management: Participants perceived being met with distrust by social workers, follow-up assessments were too frequent, unnecessary, and did not target concussion, and rehabilitation was referred too late. Clinical practice guidelines to improve referral to relevant concussion rehabilitation in case of persistent symptoms are needed to inform clinicians, employers, and public institutions to facilitate a successful RTW.

Concussion knowledge, attitudes and behaviour in equestrian athletes

OBJECTIVE

To determine knowledge, attitudes and behaviour towards concussion in adult equestrian athletes.

DESIGN

Nationwide, cross-sectional, questionnaire.

METHODS

Participants were recruited via advertisements circulated through social media, community presentations and equestrian organisations. Participants were sent a web link to an online questionnaire previously designed for high school athletes and modified to ensure relevance to equestrian activities. The percentage of correct responses per item and a total knowledge score were calculated. Differences in concussion knowledge by age, sex, level of experience and previous history of concussion were explored using t-tests, 95% confidence intervals (CI) and effect sizes.

RESULTS

The questionnaire was completed by 1486 participants (Mean age=39.1±15.4). Knowledge of what concussion was, how to recognise it and key symptoms (except poor sleep) was high (>80%). In contrast, awareness of guidelines was moderate (56%) and inability of helmets to prevent concussion was low (12%). Significantly higher levels of knowledge of concussion were identified in females compared with males (t=-6.55 p<0.001, 95%CI=-3.26 to -1.75). The majority (87%) of participants reported that a helmet should be replaced after a fall, yet 46% reported re-using a helmet following a hit to the head.

CONCLUSIONS

Knowledge of and attitudes towards concussion were positive. However, there were knowledge gaps and discrepancies between some attitudes and behaviour on some aspects of concussion. Targeted campaigns to promote awareness of concussion and improve recognition and onward management are needed. Education related to equestrian activities such as helmet use and injury mechanisms is needed to change behaviour and minimise the risk of injury.

Acute Dilation of Venous Sinuses in Animal Models of Mild Traumatic Brain Injury Detected Using 9.4T MRI

Mild traumatic brain injury (mTBI) is a debilitating but extremely common form of brain injury that affects a substantial number of people each year. mTBI is especially common in children and adolescents. Our understanding of mTBI pathophysiology is limited, and there is currently no accepted marker for disease severity. A potential marker for disease severity may be cerebrovascular dysfunction. Recent findings have implicated cerebrovascular alteration as an important component of mTBI and suggest it contributes to the development of persistent, long-term symptoms. In this paper, we conducted two studies to investigate whether mTBI affects venous drainage patterns in the central nervous system using alterations in the size of venous sinuses as a marker of changes in drainage. Using a closed head vertical weight-drop model and a lateral impact injury model of mTBI, we imaged and quantified the size of three major draining vessels in the adolescent rat brain using 9.4T MRI. Areas and volumes were quantified in the superior sagittal sinus and left and right transverse sinuses using images acquired from T2w MRI in one study and post-gadolinium T1w MRI in another. Our results indicated that the three venous sinuses were significantly larger in mTBI rats as compared to sham rats 1-day post injury but recovered to normal size 2 weeks after. Acutely enlarged sinuses post-mTBI may indicate abnormal venous drainage, and this could be suggestive of a cerebrovascular response to trauma.

Rasch analysis of the World Health Organization Disability Assessment Schedule 2.0 in a mild traumatic brain injury sample

In this study we examined the psychometric properties of the World Health Organization Disability Assessment Schedule (WHODAS 2.0 12-item version) in a mild traumatic brain injury (MTBI) sample.Materials and Methods: Treatment-seeking adults (n = 131) with MTBI recruited from outpatient clinics in Vancouver Canada, were assessed 1- and 3-months following clinic intake. Dimensionality, reliability, and differential item functioning of the WHODAS 2.0 were examined with Rasch analysis. Associations between change in WHODAS 2.0 scores and symptom, work and perceived improvement outcomes were examined.Results: Adequate fit to the Rasch model was achieved for 1-month follow-up assessment WHODAS 2.0 scores without altering the response format or item content [X² (24, n = 130) = 21.2, p = .6]. The best model fit for 3-month follow-up assessment scores was achieved when two items (problems with dressing and washing) were combined [X² (22, n = 115) = 20.9, p = .5]. Associations were evident between changes in WHODAS total Rasch scores and other outcome indicators such as return to productivity and percieved improvement.Conclusions: The WHODAS 2.0 (12-item version) is a psychometrically sound measure of functional outcome for adults seeking treatment following MTBI. Our table of ordinal to interval score conversions is recommended for future research examining MTBI outcomes.

Neuroprotection Following Concussion: The Potential Role for Cannabidiol

Cannabidiol (CBD) has been generating increasing interest in medicine due to its therapeutic properties and an apparent lack of negative side effects. Research has suggested that high dosages of CBD can be taken acutely and chronically with little to no risk. This review focuses on the neuroprotective effects of a CBD, with an emphasis on its implications for recovering from a mild traumatic brain injury (TBI) or concussion. CBD has been shown to influence the endocannabinoid system, both by affecting cannabinoid receptors and other receptors involved in the endocannabinoid system such as vanilloid receptor 1, adenosine receptors, and 5-hydroxytryptamine via cannabinoid receptor-independent mechanisms. Concussions can result in many physiological consequences, potentially resulting in post-concussion syndrome. While impairments in cerebrovascular and cardiovascular physiology following concussion have been shown, there is unfortunately still no single treatment available to enhance recovery. CBD has been shown to influence the blood brain barrier, brain-derived neurotrophic factors, cognitive capacity, the cerebrovasculature, cardiovascular physiology, and neurogenesis, all of which have been shown to be altered by concussion. CBD can therefore potentially provide treatment to enhance neuroprotection by reducing inflammation, regulating cerebral blood flow, enhancing neurogenesis, and protecting the brain against reactive oxygen species. Double-blind randomized controlled trials are still required to validate the use of CBD as medication following mild TBIs, such as concussion.

Improving symptom burden in adults with persistent post-concussive symptoms: a randomized aerobic exercise trial protocol

BACKGROUND

Persistent post-concussive symptoms (PPCS) affect up to 30% of individuals following mild traumatic brain injury. PPCS frequently includes exercise intolerance. Sub-symptom threshold aerobic exercise has been proposed as a treatment option for symptom burden and exercise intolerance in this population. The primary aim of this study is to evaluate whether a progressive, sub-symptom threshold aerobic exercise program can alleviate symptom burden in adults with PPCS.

METHODS

Fifty-six adults (18-65) with PPCS (>3mos-5 yrs) will be randomized into two groups: an immediate start 12-week aerobic exercise protocol (AEP) or delayed start 6-week placebo-like stretching protocol (SP), followed by AEP. Aerobic or stretching activities will be completed 5x/week for 30 mins during the intervention. Online daily activity logs will be submitted. Exercise prescriptions for the AEP will be 70-80% of heart rate at the point of symptom exacerbation achieved on a treadmill test with heart rate monitoring. Exercise prescription will be updated every 3-weeks with a repeat treadmill test. The Rivermead Post-concussion Symptom Questionnaire will be the primary outcome measure at 6 and 12-weeks of intervention. Secondary outcomes include assessments of specific symptoms (headache, quality of life, mood, anxiety, fatigue, dizziness, sleep parameters, daytime sleepiness) in addition to blood biomarkers and magnetic resonance imaging and spectroscopy data for quantification of brain metabolites including γ-aminobutyric acid (GABA), glutathione, glutamate and N-acetyl aspartate (NAA) all measured at 6 and 12-weeks of intervention.

DISCUSSION

This trial will evaluate the use of aerobic exercise as an intervention for adults with PPCS, thus expanding our knowledge of this treatment option previously studied predominantly for adolescent sport-related concussion.

TRIAL REGISTRATION

ClinicalTrials.gov - NCT03895450 (registered 2019-Feb-11).

Perceived Change in Physical, Cognitive, and Emotional Symptoms after Mild Traumatic Brain Injury in Patients with Pre-Injury Anxiety or Depression

The objective of this study was to compare patients with acute-to-subacute mild traumatic brain injury (mTBI) on post-concussion symptom reporting based on whether they retrospectively recalled experiencing pre-injury anxiety or depression. Patients with mTBI (n = 297; 40.4% men; mean = 38.2 years old, standard deviation [SD] = 14.0, range = 17-65), referred from an emergency department in Taipei, Taiwan, were seen in a neurosurgical outpatient clinic on average 7.7 days since injury (SD = 5.7, range = 0 - 21 days), at which time they completed a checklist of post-concussion symptoms. Patients rated their current symptom severity and retrospectively rated their pre-injury symptom severity on 15 physical, cognitive, and emotional symptoms. Patients were grouped based on whether they did or did not have mild or greater pre-injury anxiety or depression based on this scale. Those with pre-injury anxiety or depression had greater pre-injury (all p's < 0.001, d range: 0.92-2.03) and post-injury (all p's < 0.001, d range: 0.65-1.00) symptom severity. However, when analyzing perceived change in symptoms (i.e., post-injury ratings minus pre-injury ratings), only perceived change in cognitive symptoms differed across groups (p = 0.018, d = 0.29), which became non-significant after controlling for gender. Greater post-concussion symptom severity in patients with pre-existing mental health problems may be mostly attributable to elevated symptoms before injury. These findings demonstrate the clinical value of retrospective pre-injury symptom assessment in mTBI management. Greater post-concussion symptom severity in patients with pre-injury mental health problems may represent a continuation of greater pre-injury symptom severity rather than a greater increase in symptom severity after mTBI.

Three methods for examining trajectories in neuropsychological performance across the first 4 years after mild Traumatic Brain Injury

Background:

Emerging data suggest that recovery from mild traumatic brain injury (mTBI) takes longer than previously thought. This paper examines trajectories for cognitive recovery up to 48 months post-mTBI, presenting these visually using a Sankey diagram and growth curve analysis.

Methods:

This sample (n = 301) represents adults (≥16 years) from a population-based Brain Injury Outcomes in the New Zealand Community study over a 4-year follow-up on the CNS-Vital Signs neuropsychological test. Data were collected within 2 weeks of injury, and then at 1, 6, 12 and 48 months post-injury.

Results:

Significant improvement in cognitive functioning was seen up to 6 months post-injury. Using growth curve modelling, we found significant improvements in overall neurocognition from baseline to 6 months, on average participants improved one point per month (0.9; 95% CI 0.42–1.39) p < 0.001. No change in neurocognition was found within the time periods 6–12 months or 12–48 months. The Sankey highlighted that at each time point, a small proportion of participants remained unchanged or declined. Proportionally, few show any improvement after the first 6 months.

Conclusion:

Most individuals remained stable or improved over time to 6 months post-injury. Summary statistics are informative regarding overall trends, but can mask differing trajectories for recovery. The Sankey diagram indicates that not all improve, as well as the potential impact of individuals moving in and out of the study. The Sankey diagram also indicated the level of functioning of those most likely to withdraw, allowing targeting of retention strategies.

Can the Neck Contribute to Persistent Symptoms Post Concussion? A Prospective Descriptive Case Series

BACKGROUND

Persistent symptoms post concussion can arise from a range of sources, including the neck. There is little description of neck assessment findings in people with persistent symptoms post concussion.

OBJECTIVES

To assess people with persistent symptoms following a concussion and determine whether the neck has also been injured, and to evaluate the potential of the neck to contribute to their symptoms.

METHODS

A consecutive series of participants (n = 20) referred for neck assessment were prospectively recruited by 2 providers of a multidisciplinary concussion service for people with persistent symptoms. Data were collected at initial assessment and on completion of neck treatment, which included standard questionnaires (Rivermead Post Concussion Symptoms Questionnaire, Neck Disability Index, Dizziness Handicap Inventory); patient-reported measures of headache, dizziness, and neck pain; physical examination findings; and details of comorbidities.

RESULTS

Participants were evaluated at a mean of 7.5 weeks post concussion (median, 5 weeks). On neck assessment, 90% were considered by the clinician to have a neck problem contributing to their current symptoms. Multiple findings were consistent with this view, including moderate-to-severe Neck Disability Index scores (mean ± SD, 33.4 ± 9.5 points), frequent neck pain (85%), frequent moderate-to-severe pain on occiput-C4 segmental assessment (85%), a positive flexion-rotation test (45%), and muscle tenderness (50%-55%).

CONCLUSION

Multiple findings were indicative of concurrent neck injury, particularly involving the upper cervical spine. These neck-related findings are important to recognize, as they have the potential to contribute to persistent symptoms post concussion and may respond to neck treatment. This study was prospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12616001183471). J Orthop Sports Phys Ther 2019;49(11):845-854. Epub 1 Jun 2019. doi:10.2519/jospt.2019.8547.

The association between health-related quality of life and noise or light sensitivity in survivors of a mild traumatic brain injury

PURPOSE

Sensory impairment is a common aftereffect of mild traumatic brain injury (TBI); however, their influence upon treatment outcomes and quality of life has yet to be investigated. This study sought to determine the effects of noise and light sensitivity upon the quality of life of individuals diagnosed with a TBI.

METHODS

A cross-sectional adult sample obtained from a longitudinal study (n = 293) provided measures of light and noise sensitivity and quality of life 12 months post injury. Sensitivities were taken from the Rivermead Post-concussion Symptoms Questionnaire, while quality of life was estimated using the Short-Form 36 health survey (SF-36).

RESULTS

Approximately 42% of participants reported ongoing difficulties with noise and light sensitivity. Additionally, those reporting sensory difficulties also reported lower SF-36 domain and composite scores compared to those reporting no such symptoms. After controlling for known co-factors, hierarchical multiple regression analyses indicated that the combination of light and noise sensitivity explained between 8 and 35% of the variance in SF-36 scores.

CONCLUSIONS

Light and noise sensitivity appear to degrade the quality of life of those with a mild TBI. Our findings challenge contemporary rehabilitation practices that tend to sideline sensory complaints and instead focus on the remediation of acute TBI symptoms.

Randomised controlled clinical trial of a structured cognitive rehabilitation in patients with attention deficit following mild traumatic brain injury: study protocol

OBJECTIVES

To measure the clinical, structural and functional changes of an individualised structured cognitive rehabilitation in mild traumatic brain injury (mTBI) population.

SETTING

A single centre study, Malaysia.

PARTICIPANTS

Adults aged between 18 and 60 years with mTBI as a result of road traffic accident, with no previous history of head trauma, minimum of 9 years education and abnormal cognition at 3 months will be included. The exclusion criteria include pre-existing chronic illness or neurological/psychiatric condition, long-term medication that affects cognitive/psychological status, clinical evidence of substance intoxication at the time of injury and major polytrauma. Based on multiple estimated calculations, the minimum intended sample size is 50 participants (Cohen's d effect size=0.35; alpha level of 0.05; 85% power to detect statistical significance; 40% attrition rate).

INTERVENTIONS

Intervention group will receive individualised structured cognitive rehabilitation. Control group will receive the best patient-centred care for attention disorders. Therapy frequency for both groups will be 1 hour per week for 12 weeks.

OUTCOME MEASURES

Primary: Neuropsychological Assessment Battery-Screening Module (S-NAB) scores. Secondary: Diffusion Tensor Imaging (DTI) parameters and Goal Attainment Scaling score (GAS).

RESULTS

Results will include descriptive statistics of population demographics, CogniPlus cognitive program and metacognitive strategies. The effect of intervention will be the effect size of S-NAB scores and mean GAS T scores. DTI parameters will be compared between groups via repeated measure analysis. Correlation analysis of outcome measures will be calculated using Pearson's correlation coefficient.

CONCLUSION

This is a complex clinical intervention with multiple outcome measures to provide a comprehensive evidence-based treatment model.

ETHICS AND DISSEMINATION

The study protocol was approved by the Medical Research Ethics Committee UMMC (MREC ID NO: 2016928-4293). The findings of the trial will be disseminated through peer-reviewed journals and scientific conferences.

TRIAL REGISTRATION NUMBER

NCT03237676.

Validity and reliability of the Neuropsychological Assessment Battery - Screening Module (S-NAB) in a subset of Malaysian population with mild traumatic brain injury (mTBI)

This study assessed the validity (construct validity) and reliability (internal consistency) of the Neuropsychological Assessment Battery Screening Module (S-NAB) in detecting mild cognitive deficit/alteration in multicultural, multilingual, and multiethnic mild traumatic brain injury (mTBI) population of Malaysia. S-NAB and Montreal Cognitive Assessment (MoCA) data from 114 patients with mTBI (93 males; 21 females) aged 18 to 60 years old were obtained at University Malaya Medical Center, Malaysia. The mean age was 28.17 ± 8.57 years and mean education years was 12.40 ± 2.01. Convergent validity was assessed between S-NAB domain scores and MoCA total scores by using Pearson's correlation and internal consistency was assessed using Cronbach's alpha. Acceptable internal consistency (α ≥ .70) was found for Attention, Language, and Memory domains but weak internal consistencies (α < .50) were found for Spatial and Executive Function domains. There were positive but weak correlations between S-NAB and MoCA. These findings provide some support for the application of S-NAB in assessing mild cognitive deficits of mTBI population in a Malaysian setting.

Predictive factors of quality of life in acquired brain injury

The sequelae and the disability and dependence that follow an acquired brain injury (ABI) may result in a significant reduction in the quality of life (QoL) of those affected. The objective was to assess the QoL of a sample of Spanish patients with an ABI and analyze the influence of certain sociodemographic and injury-related variables on their QoL. Method: The sample comprised 421 adults (60% male; M_age = 53.12; SD = 14.87). Professionals and relatives assessed the patients’ QoL through the CAVIDACE scale, an ABI-specific tool based on the eight-domain QoL model. Results: Univariate analyses showed statistically significant differences in the QoL scores in several sociodemographic (age, civil status, education level, prior employment status, type of home, level of supports, loss of legal capacity, recognized dependence, and degree of dependence) and injury-related (time since the injury, location of the injury, and presence of post-traumatic amnesia) variables. The multiple linear regression showed that loss of legal capacity, time since the injury, prior employment status, location of the injury, and degree of dependence were significant QoL predictors. Conclusions: These findings provide knowledge for the development of programs aimed at reducing the negative impact of ABI on QoL.

Assessment of executive function in bilingual adults with history of mild traumatic brain injury

Background and objective:

Adults with a history of traumatic brain injury (TBI) often show deficits in executive function (EF), including the ability to inhibit, switch, and attend to task relevant information. Although performances differences between bilinguals and monolinguals have been observed in EF tasks, there is little research on the effect of TBI on EF in bilinguals. In this study, an ecologically valid standardized measure and experimental computerized tasks of EF were administered to Spanish-English bilingual adults with and without history of mild traumatic brain injury (mTBI).

Method:

Twenty-two bilinguals with a history of mTBI [mean age=20.1 years, SD=3.7; education=13.4 years, SD=0.7] and 20 control bilinguals [mean age=20.8 years, SD=3.6; education=13.7 years, SD=1.1], matched for age and education, completed language proficiency questionnaires, the Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES), English and Spanish language assessments, and a Flanker task (a test of inhibition).

Results:

Performance was analyzed using analyses of covariance. The results revealed that bilinguals with a history of mTBI performed worse on both the standardized assessment (FAVRES) and inhibition task. Interestingly, self-reported EF deficits were consistent with performance on these measures.

Conclusion:

The findings of this study provide useful information regarding assessment of EF deficits in bilinguals with a history mTBI. Computerized experimental tasks of EF may also prove useful in the assessment of EF in individuals with mTBI.

Prior head injury but not sex or sports-participation affects expectations for post-injury rest and activity in simulated mild traumatic brain injury

Rest acutely followed by a gradual return to activity is commonly recommended for mild traumatic brain injury (TBI). However, the general public's rest and activity expectations for this injury are unknown, as are the individual factors that might affect them. 165 individuals completed an online survey. A series of between-groups comparisons of expectations for the week following a mild TBI was performed. The comparisons were between individuals with or without a prior mild TBI; sports-playing versus non-sports-playing individuals, and; females versus males. Expectations were elicited for 39 everyday behaviours referred to in mild TBI patient advice. Compared to a rating indicating 'no change' in the amount of pre-injury activity, "rest" was expected for 37 items (p's < .05). Expectations were not different based on participants' sex or sports-participation. However, for seven predominantly cognitive items such as studying, a prior injury increased rest expectations (p < .05; small-to-medium effects). The findings indicate that whilst the proposed activity restrictions are appropriate for some circumstances such as acutely postinjury, they have the potential to be overly strong. To address this potential, especially with first-ever injury, clinicians and sports officials should check their patient's postinjury rest and activity plans when providing active rest advice.

Predicting mood outcome following traumatic brain injury (TBI): PTA & demographic variables

Background and aims:

Mood disturbance is frequent after traumatic brain injury (TBI), often assessed using the Hospital Anxiety and Depression Scale (HADS). Research supports a three-factor HADS structure (anxiety, depression, and psychomotor), although this has not been used to investigate demographic variables and mood outcome post-TBI. This study examined severity of TBI, demographic variables [age, gender, estimated premorbid IQ (EIQ), relationship status, employment status, socio-economic status (SES)], and mood outcome, using HADS factor scores from a large adult population sample in Tasmania.

Method:

HADS factor scores were calculated for an initial sample of 596 adults. The sample sizes varied according to those attending at 1, 6, 12 and 24 months post-TBI and the available data for each dependent variable.

Results:

Significantly higher anxiety, depression, and psychomotor scores were reported at most follow-ups by females, the middle-aged, and those with lower IQs. Longer post-traumatic amnesia (PTA) was associated with significantly greater mood problems. Occasional significant findings at earlier follow-ups for the factors were noted for those unemployed. Other variables were rarely significant. PTA, premorbid IQ, and Age were included in most Multiple Regression equations predicting outcome for the factors, with Gender included for Anxiety and depression at 6 months after injury.

Conclusions:

Key demographic variables and PTA severity relate to mood post-TBI, and contribute to predicting mood outcome. Differences in findings for the three factors support their use in clinical practice.

Head trauma in sports - clinical characteristics, epidemiology and biomarkers

Traumatic brain injury (TBI) is clinically divided into a spectrum of severities, with mild TBI being the least severe form and a frequent occurrence in contact sports, such as ice hockey, American football, rugby, horse riding and boxing. Mild TBI is caused by blunt nonpenetrating head trauma that causes movement of the brain and stretching and tearing of axons, with diffuse axonal injury being a central pathogenic mechanism. Mild TBI is in principle synonymous with concussion; both have similar criteria in which the most important elements are acute alteration or loss of consciousness and/or post-traumatic amnesia following head trauma and no apparent brain changes on standard neuroimaging. Symptoms in mild TBI are highly variable and there are no validated imaging or fluid biomarkers to determine whether or not a patient with a normal computerized tomography scan of the brain has neuronal damage. Mild TBI typically resolves within a few weeks but 10-15% of concussion patients develop postconcussive syndrome. Repetitive mild TBI, which is frequent in contact sports, is a risk factor for a complicated recovery process. This overview paper discusses the relationships between repetitive head impacts in contact sports, mild TBI and chronic neurological symptoms. What are these conditions, how common are they, how are they linked and can they be objectified using imaging or fluid-based biomarkers? It gives an update on the current state of research on these questions with a specific focus on clinical characteristics, epidemiology and biomarkers.

Network Analysis and Precision Rehabilitation for the Post-concussion Syndrome

Some people experience persistent symptoms following a mild traumatic brain injury (MTBI), and the etiology of those symptoms has been debated for generations. Post-concussion-like symptoms are caused by many factors both before and after MTBI, and this non-specificity is the bedrock of the conundrum regarding the existence of the post-concussion syndrome. A latent model or common cause theory for the syndrome is inconsistent with the prevailing biopsychosocial conceptualization. It is the thesis of this paper that adopting a network perspective for persistent symptoms following MTBI, including the post-concussion syndrome, could lead to new insights and targeted treatment and rehabilitation strategies. The network perspective posits that symptoms co-occur because they are strongly inter-related, activating, amplifying, and mutually reinforcing, not because they arise from a common latent disease entity. This approach requires a conceptual shift away from thinking that symptoms reflect an underlying disease or disorder toward viewing inter-related symptoms as constituting the syndrome or disorder. The symptoms do not arise from an underlying syndrome—the symptoms are the syndrome. A network analysis approach allows us to embrace heterogeneity and comorbidity, and it might lead to the identification of new approaches to sequenced care. The promise of precision rehabilitation requires us to better understand the interconnections among symptoms and problems so that we can produce more individualized and effective treatment and rehabilitation.

Premorbid risk factors influencing labour market attachment after mild traumatic brain injury: a national register study with long-term follow-up

OBJECTIVES

Some patients with mild traumatic brain injury (mTBI) experience persistent postconcussive symptoms, influencing the ability to work. This study assessed associations between mTBI and labour market attachment (up to 5 years postinjury) in patients with different premorbid characteristics.

DESIGN AND SETTING

Danish national cohort study with 5-year register follow-up.

PARTICIPANTS

We included hospital admitted patients between 18 and 60 years diagnosed with mTBI (International Classification of Diseases, version 10 diagnosis S06.0) (n=19 732). For each patient, one control was selected matched on age, gender and municipality (n=18 640).

PRIMARY OUTCOME MEASURE

Primary outcome was 'not attending ordinary work', and premorbid risk factors were cohabitation status, education, ethnicity, gender, age and comorbidities.

RESULTS

The odds of not attending ordinary work increased from 6 months to 5 years. The highest increased odds (approximately twice as high for patients) of not attending ordinary work at 5 years were found in the highest educational group (OR 2.15, 95% CI 1.78 to 2.59), for patients of non-Danish origin (OR 1.98, 95% CI 1.52 to 2.57), for patients between 30 and 39 years (OR 1.93, 95% CI 1.68 to 1.23) and for patients with somatic comorbidities (OR 1.81, 95% CI 1.38 to 2.37). Contrary to expectations, we did not find higher odds in patients with psychiatric diagnoses (OR 1.12, 95% CI 0.76 to 1.60).

CONCLUSIONS

Important premorbid characteristics for lower labour market participation after mTBI were higher education, non-Danish origin, age 30-39 years and having somatic comorbidities. Demographic and health-related variables should be considered when assessing patients with mTBI at risk of long-term sickness absence.

TRIAL REGISTRATION NUMBER

NCT03214432; Results.

Early, specialist vocational rehabilitation to facilitate return to work after traumatic brain injury: the FRESH feasibility RCT

BACKGROUND

Up to 160,000 people incur traumatic brain injury (TBI) each year in the UK. TBI can have profound effects on many areas of human functioning, including participation in work. There is limited evidence of the clinical effectiveness and cost-effectiveness of vocational rehabilitation (VR) after injury to promote early return to work (RTW) following TBI.

OBJECTIVE

To assess the feasibility of a definitive, multicentre, randomised controlled trial (RCT) of the clinical effectiveness and cost-effectiveness of early, specialist VR plus usual care (UC) compared with UC alone on work retention 12 months post TBI.

DESIGN

A multicentre, feasibility, parallel-group RCT with a feasibility economic evaluation and an embedded mixed-methods process evaluation. Randomisation was by remote computer-generated allocation.

SETTING

Three NHS major trauma centres (MTCs) in England.

PARTICIPANTS

Adults with TBI admitted for > 48 hours and working or studying prior to injury.

INTERVENTIONS

Early specialist TBI VR delivered by occupational therapists (OTs) in the community using a case co-ordination model.

MAIN OUTCOME MEASURES

Self-reported RTW 12 months post randomisation, mood, functional ability, participation, work self-efficacy, quality of life and work ability. Feasibility outcomes included recruitment and retention rates. Follow-up was by postal questionnaires in two centres and face to face in one centre. Those collecting data were blind to treatment allocation.

RESULTS

Out of 102 target participants, 78 were recruited (39 randomised to each arm), representing 39% of those eligible and 5% of those screened. Approximately 2.2 patients were recruited per site per month. Of those, 56% had mild injuries, 18% had moderate injuries and 26% had severe injuries. A total of 32 out of 45 nominated carers were recruited. A total of 52 out of 78 (67%) TBI participants responded at 12 months (UC, n = 23; intervention, n = 29), completing 90% of the work questions; 21 out of 23 (91%) UC respondents and 20 out of 29 (69%) intervention participants returned to work at 12 months. Two participants disengaged from the intervention. Face-to-face follow-up was no more effective than postal follow-up. RTW was most strongly related to social participation and work self-efficacy. It is feasible to assess the cost-effectiveness of VR. Intervention was delivered as intended and valued by participants. Factors likely to affect a definitive trial include deploying experienced OTs, no clear TBI definition or TBI registers, and repatriation of more severe TBI from MTCs, affecting recruitment of those most likely to benefit/least likely to drop out.

LIMITATIONS

Target recruitment was not reached, but mechanisms to achieve this in future studies were identified. Retention was lower than expected, particularly in UC, potentially biasing estimates of the 12-month RTW rate.

CONCLUSIONS

This study met most feasibility objectives. The intervention was delivered with high fidelity. When objectives were not met, strategies to ensure feasibility of a full trial were identified. Future work should test two-stage recruitment and include resources to recruit from 'spokes'. A broader measure covering work ability, self-efficacy and participation may be a more sensitive outcome.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN38581822.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 33. See the NIHR Journals Library website for further project information.

Pre-injury Comorbidities Are Associated With Functional Impairment and Post-concussive Symptoms at 3- and 6-Months After Mild Traumatic Brain Injury: A TRACK-TBI Study

Introduction: Over 70% of traumatic brain injuries (TBI) are classified as mild (mTBI), which present heterogeneously. Associations between pre-injury comorbidities and outcomes are not well-understood, and understanding their status as risk factors may improve mTBI management and prognostication. Methods: mTBI subjects (GCS 13-15) from TRACK-TBI Pilot completing 3- and 6-month functional [Glasgow Outcome Scale-Extended (GOSE)] and post-concussive outcomes [Acute Concussion Evaluation (ACE) physical/cognitive/sleep/emotional subdomains] were extracted. Pre-injury comorbidities >10% incidence were included in regressions for functional disability (GOSE ≤ 6) and post-concussive symptoms by subdomain. Odds ratios (OR) and mean differences (B) were reported. Significance was assessed at p < 0.0083 (Bonferroni correction). Results: In 260 subjects sustaining blunt mTBI, mean age was 44.0-years and 70.4% were male. Baseline comorbidities >10% incidence included psychiatric-30.0%, cardiac (hypertension)-23.8%, cardiac (structural/valvular/ischemic)-20.4%, gastrointestinal-15.8%, pulmonary-15.0%, and headache/migraine-11.5%. At 3- and 6-months separately, 30.8% had GOSE ≤ 6. At 3-months, psychiatric (GOSE ≤ 6: OR = 2.75, 95% CI [1.44-5.27]; ACE-physical: B = 1.06 [0.38-1.73]; ACE-cognitive: B = 0.72 [0.26-1.17]; ACE-sleep: B = 0.46 [0.17-0.75]; ACE-emotional: B = 0.64 [0.25-1.03]), headache/migraine (GOSE ≤ 6: OR = 4.10 [1.67-10.07]; ACE-sleep: B = 0.57 [0.15-1.00]; ACE-emotional: B = 0.92 [0.35-1.49]), and gastrointestinal history (ACE-physical: B = 1.25 [0.41-2.10]) were multivariable predictors of worse outcomes. At 6-months, psychiatric (GOSE ≤ 6: OR = 2.57 [1.38-4.77]; ACE-physical: B = 1.38 [0.68-2.09]; ACE-cognitive: B = 0.74 [0.28-1.20]; ACE-sleep: B = 0.51 [0.20-0.83]; ACE-emotional: B = 0.93 [0.53-1.33]), and headache/migraine history (ACE-physical: B = 1.81 [0.79-2.84]) predicted worse outcomes. Conclusions: Pre-injury psychiatric and pre-injury headache/migraine symptoms are risk factors for worse functional and post-concussive outcomes at 3- and 6-months post-mTBI. mTBI patients presenting to acute care should be evaluated for psychiatric and headache/migraine history, with lower thresholds for providing TBI education/resources, surveillance, and follow-up/referrals. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT01565551.

Cognitive Impairment Following Acute Mild Traumatic Brain Injury

Patients with mild traumatic brain injury (mTBI) may present cognitive deficits within the first 24 h after trauma, herein called "acute phase," which in turn may lead to long-term functional impairment and decrease in quality of life. Few studies investigated cognition in mTBI patients during the acute phase. The objectives of this study were to investigate the cognitive profile of patients with mTBI during the acute phase, compared to controls and normative data, and whether loss of consciousness (LOC), previous TBI and level of education influence cognition at this stage. Fifty-three patients with mTBI (aged 19-64 years) and 28 healthy controls participated in the study. All patients were evaluated at bedside within 24 h post-injury. Demographic and clinical data were registered. Cognitive function was assessed with the Mini-mental state examination (MMSE), the Frontal Assessment Battery (FAB), Digit Span (working memory), and the Visual Memory Test/Brief Cognitive Battery (for episodic memory). The clinical sample was composed mainly by men (58.5%). The mean age was 39 years-old and 64.3% of the patients had more than 8 years of education. The most common causes of mTBI were fall from own height (28.3%), aggression (24.5%), and fall from variable heights (24.5%). Compared to controls, mTBI patients exhibited significantly worse performance on MMSE, FAB, naming, incidental memory, immediate memory, learning, and delayed recall. Compared to normative data, 26.4% of patients had reduced global cognition as measured by the MMSE. Episodic memory impairment (13.2%) was more frequent than executive dysfunction (9.4%). No significant differences were found in cognitive performance when comparing patients with or without LOC or those with or without history of previous TBI. Patients with lower educational level had higher rates of cognitive impairment (VMT naming-28.6 vs. 4.2%; VMT immediate memory-32 vs. 4.2%; VMT learning-39.3 vs. 4.2%, all p < 0.05). In sum, we found significant cognitive impairment in the acute phase of mTBI, which was not associated with LOC or history of TBI, but appeared more frequently in patients with lower educational level.

Is it really the result of a concussion? Lessons from a case study

Background

Within the last two decades, attitudes have shifted from considering sports-related concussion as an insignificant minor injury with no long-term repercussions to a potentially serious brain injury garnering attention from media, clinicians, researchers, and the general public.

Objectives

To conduct a case study to determine the underlying cause of persistent issues suspected to be associated with a history of sports-related concussion.

Protocol

Participant A underwent neurophysiological testing following the Neary protocol (assessment of cerebrovascular and cardiovascular variables), comprehensive concussion assessment at a dedicated sports concussion clinic (history, neurological assessment, cervical spine screening, vestibulo-ocular screening, SCAT-5, and exercise testing), referral to a neurologist, structural MRI scan, and referral for specialised assessment at a dedicated dizziness and balance centre.

Results

Despite a history of multiple sports-related concussions, Participant A’s persistent symptom reports were associated with peripheral vestibular dysfunction and otolithic dysfunction seemingly unrelated to his concussion history.

Discussion

Lessons from Participant A’s case study showed that on-going symptoms that patients may associate with the effects of concussions may instead be due to unrelated causes that share similar symptomology.

Conclusion

This research exemplifies the importance of a multi-disciplinary assessment using a repeated testing protocol.

Vocational Rehabilitation in Mild Traumatic Brain Injury: Supporting Return to Work and Daily Life Functioning

Persisting post-concussive symptoms are challenging to treat and may delay return-to-work (RTW). The aims of this study were to describe a multidisciplinary and holistic vocational rehabilitation (VR) program for individuals with mild traumatic brain injury (mTBI) and to explore course and predictors of employment outcome during VR. The VR program was described using the Standard Operating Procedures (SOPs) framework. Further, a retrospective, cohort study on individuals with mTBI receiving VR was conducted based on clinical records (n = 32; 22% males; mean age 43.2 years; 1.2 years since injury on average). The primary outcome was difference in hours at work per week from pre- to post-VR, and the secondary outcome was change in a three-level RTW-status. Time since injury, age, sex, and loss of consciousness were investigated as predictors of the outcomes. The VR intervention is individually tailored and targets patients' individual needs. Thus, it may combine a variety of methods based on a biopsychosocial theoretical model. During VR, hours at work, 17.0 ± 2.2, p < 0.001, and RTW-status, OR = 14.0, p < 0.001, improved significantly with 97% having returned to work after VR. Shorter length of time since injury and male sex were identified as predictors of a greater gain of working hours. Time since injury was the strongest predictor; double the time was associated with a reduction in effect by 4.2 ± 1.4 h after adjusting for working hours at start of VR. In sum, these results suggest that individuals facing persistent problems following mTBI may still improve employment outcomes and RTW after receiving this multidisciplinary and holistic VR intervention, even years after injury. While results are preliminary and subject to bias due to the lack of a control group, this study warrants further research into employment outcomes and VR following mTBI, including who may benefit the most from treatment.

How often is neck and vestibulo-ocular physiotherapy treatment recommended in people with persistent post-concussion symptoms? A retrospective analysis

BACKGROUND

Persistent post-concussion symptoms (PPCS) are complex, and typically involve multidisciplinary assessment and management. The neck and vestibulo-ocular systems are recognised as potential contributors to PPCS, yet it is not clear how often treatment for these systems is warranted.

OBJECTIVES

To explore how often neck and vestibulo-ocular treatment is received or recommended in people with PPCS.

DESIGN

Retrospective chart review.

METHOD

De-identified clinical service data for the calendar year of 2017 were extracted from a single concussion service provider in Dunedin, New Zealand. A summary of the individual assessments and treatments received were extracted and used to determine how often cases were considered to require physician or neuropsychological assessment; and how often cases received or were recommended neck and/or vestibulo-ocular physiotherapy treatment.

RESULTS/FINDINGS

147 cases were included in this study. Physician assessment was considered required in 25 cases (17%), and neuropsychological assessment in 90 cases (61%). For physiotherapy, neck treatment was received or recommended in 80 cases (54%), and vestibulo-ocular treatment in 106 cases (72%). Notably, this included 59 cases (40%) where both neck and vestibulo-ocular treatment were received or recommended.

CONCLUSIONS

The high proportion of cases receiving or recommended neck and vestibulo-ocular treatment strongly suggests both these systems often contribute to PPCS, often in overlap. While based on retrospective data, these findings highlight the value of routine neck and vestibulo-ocular examination in the assessment and management of PPCS. Further prospective study would be beneficial to explore these proportions in more detail and in other regions.

Wrestling with uncertainty after mild traumatic brain injury: a mixed methods study

Purpose: Our objective was to explore the intersection between mild traumatic brain injury (MTBI) recovery experiences and injury understandings, using both quantitative and qualitative methods.Materials and Methods: The quantitative component was a descriptive case-control study comparing participants (n = 76) who had recovered or not recovered after an MTBI, across demographic and psychological variables. A subset of participants (n = 10) participated in a semi-structured interview to explore experiences of recovery in more detail. We followed threads across the datasets to integrate findings from component methods.Results: The quantitative analyses revealed differences between the two groups in terms of injury recovery understandings and expectations. The qualitative analyses suggested that achieving consistency across information sources was important. By tracing threads back and forth between the component datasets, we identified a super-ordinate meta-theme that captured participants' experiences of wrestling with uncertainty about their recovery and the impacts in terms of heightened anxiety, confusion, and feelings of invalidation.Conclusion: The effectiveness of psychoeducation and reassurance after MTBI may be optimized when content is tailored to the individual. Clinicians are urged to attend both to the subjective interpretations patients make of information gained from formal and informal, internal and external sources, and where information across these sources conflicts and creates uncertainty.Implications for rehabilitationEffectiveness of psychoeducation and reassurance after injury may be optimized when content is tailored to the individual rather than being generic.Effectiveness of such interventions may also be optimized by understanding the subjective interpretations individuals make of injury knowledge gleaned from formal and informal, internal and external sources.Conflicting information from such multiple sources may create uncertainty with associated increased distress as an individual negotiates their recovery from injury. Attending to this uncertainty may be a helpful target for treatment.

Physiological and pathological covariates of persistent concussion-related fatigue: results from two regression methodologies

BACKGROUND

Fatigue severity in persons with mild traumatic brain injury (mTBI) has received little research attention, despite its typically positively skewed nature. Investigation of covariates across a range of fatigue severity may provide insight into important contributors.

OBJECTIVE

To assess the relative significance of a priori-hypothesized covariates of physiological and pathological (mental and physical) fatigue in persons with mTBI/concussion, applying ordinary least squares (OLS) and quantile regression (QR) approaches.

METHODS

We conducted a cross-sectional investigation in 80 participants with mTBI/concussion (mean age 45.4 ± 10.1 years, 59% male). The fatigue severity scale (FSS) was used as an outcome measure. Predictors of this outcome, grouped into physiological and pathological models of fatigue were assessed using OLS and QR.

RESULTS

The mean total FSS score was 46.13 ± 14.59, and the median was 49 (interquartile range 37-57), demonstrating positive skewness. Fatigue severity was associated with variables within the mental, psychological and psychiatric domains at different levels of the fatigue score distribution.

CONCLUSION

Results highlighted that some covariates had a significant impact on the FSS total score at non-central parts of its distribution, while others exhibited significant impact across the entire distribution. Addressing covariates of fatigue across the severity continuum can enhance research and clinical management.

An experimental study of the effect on activity intentions of postconcussion recovery advice

This study tested the effect of issuing return-to-activity advice on activity intentions at Day 2 and Day 10 days post simulated mild traumatic brain injury. One hundred and twenty-eight volunteers were randomly allocated to one of two groups who received ( n =  65) or did not receive standardized post-injury advice ( n =  63). To prime the simulation, the participants read a mild traumatic brain injury vignette about a person who is concussed while playing sport. Then the participants role-played the injured person and reported activity intentions for three activity types (cognitive, physical and restful) twice, once for each time frame (i.e. Day 2 and Day 10). The advice was to rest for the first 24–48 h and then gradually resume normal activities. There was no significant group by activity-type interaction ( p > .05) at Day 2. When both time frames were considered, there was no significant group × time frame interaction for any activity type or any item, except for an increase in non-manual (clerical) work and weight training at Day 10 compared to Day 2 in the group with the advice. In general, the intentions for all activity types were consistent with the recovery advice (i.e., rest then increasing activity), even when the advice was not given. However, at Day 10, cognitive and physical activity levels were still expected to be lower than usual (pre-injury), and many participants were uncertain about the concept of cognitive rest. These factors, along with individual patient circumstances, should be taken into account in rehabilitation planning.

A Multidimensional Approach to Post-concussion Symptoms in Mild Traumatic Brain Injury

Mild traumatic brain injury (mTBI) presents a substantial burden to patients, families, and health care systems. Whereas, recovery can be expected in the majority of patients, a subset continues to report persisting somatic, cognitive, emotional, and/or behavioral problems, generally referred to as post-concussion syndrome (PCS). However, this term has been the subject of debate since the mechanisms underlying post-concussion symptoms and the role of pre- and post-injury-related factors are still poorly understood. We review current evidence and controversies concerning the use of the terms post-concussion symptoms vs. syndrome, its diagnosis, etiology, prevalence, assessment, and treatment in both adults and children. Prevalence rates of post-concussion symptoms vary between 11 and 82%, depending on diagnostic criteria, population and timing of assessment. Post-concussion symptoms are dependent on complex interactions between somatic, psychological, and social factors. Progress in understanding has been hampered by inconsistent classification and variable assessment procedures. There are substantial limitations in research to date, resulting in gaps in our understanding, leading to uncertainty regarding epidemiology, etiology, prognosis, and treatment. Future directions including the identification of potential mechanisms, new imaging techniques, comprehensive, multidisciplinary assessment and treatment options are discussed. Treatment of post-concussion symptoms is highly variable, and primarily directed at symptom relief, rather than at modifying the underlying pathology. Longitudinal studies applying standardized assessment strategies, diagnoses, and evidence-based interventions are required in adult and pediatric mTBI populations to optimize recovery and reduce the substantial socio-economic burden of post-concussion symptoms.

Update on Insomnia after Mild Traumatic Brain Injury

Sleep disturbance after traumatic brain injury (TBI) has received growing interest in recent years, garnering many publications. Insomnia is highly prevalent within the mild traumatic brain injury (mTBI) population and is a subtle, frequently persistent complaint that often goes undiagnosed. For individuals with mTBI, problems with sleep can compromise the recovery process and impede social reintegration. This article updates the evidence on etiology, epidemiology, prognosis, consequences, differential diagnosis, and treatment of insomnia in the context of mild TBI. This article aims to increase awareness about insomnia following mTBI in the hopes that it may improve diagnosis, evaluation, and treatment of sleeping disturbance in this population while revealing areas for future research.

Unraveling the Biopsychosocial Factors of Fatigue and Sleep Problems After Traumatic Brain Injury: Protocol for a Multicenter Longitudinal Cohort Study

Background

Fatigue and sleep problems are common after a traumatic brain injury (TBI) and are experienced as highly distressing symptoms, playing a significant role in the recovery trajectory, and they can drastically impact the quality of life and societal participation of the patient and their family and friends. However, the etiology and development of these symptoms are still uncertain.

Objective

The aim of this study is to examine the development of fatigue and sleep problems following moderate to severe TBI and to explore the changes in underlying biological (pain, brain damage), psychological (emotional state), and social (support family, participation) factors across time.

Methods

This study is a longitudinal multicenter observational cohort study with 4 measurement points (3, 6, 12, and 18 months postinjury) including subjective questionnaires and cognitive tasks, preceded by 7 nights of actigraphy combined with a sleep diary. Recruitment of 137 moderate to severe TBI patients presenting at emergency and neurology departments or rehabilitation centers across the Netherlands is anticipated. The evolution of fatigue and sleep problems following TBI and their association with possible underlying biological (pain, brain damage), psychological (emotional state), and social (support family, participation) factors will be examined.

Results

Recruitment of participants for this longitudinal cohort study started in October 2017, and the enrollment of participants is ongoing. The first results are expected at the end of 2020.

Conclusions

To the authors’ knowledge, this is the first study that examines the development of both post-TBI fatigue and sleep longitudinally within a biopsychosocial model in moderate to severe TBI using both subjective and objective measures. Identification of modifiable factors such as mood and psychosocial stressors may give direction to the development of interventions for fatigue and sleep problems post-TBI.

Trial Registration

Netherlands Trial Register NTR7162; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=7162 (Archived by WebCite at http://www.webcitation.org/6z3mvNLuy)

International Registered Report Identifier (IRRID)

RR1-10.2196/11295

Potential for the development of light therapies in mild traumatic brain injury

Light affects almost all aspects of human physiological functioning, including circadian rhythms, sleep-wake regulation, alertness, cognition and mood. We review the existing relevant literature on the effects of various wavelengths of light on these major domains, particularly as they pertain to recovery from mild traumatic brain injuries. Evidence suggests that light, particularly in the blue wavelengths, has powerful alerting, cognitive and circadian phase shifting properties that could be useful for treatment. Other wavelengths, such as red and green may also have important effects that, if targeted appropriately, might also be useful for facilitating recovery. Despite the known effects of light, more research is needed. We recommend a personalized medicine approach to the use of light therapy as an adjunctive treatment for patients recovering from mild traumatic brain injury.

A preliminary study to investigate the prevalence of pain in international event riders during competition, in the United Kingdom

The aim of the study was to investigate the prevalence of riders at the international levels in eventing, competing with pain, the location of their pain, factors affecting their pain and whether they perceived this pain to have an effect on their performance. 331 questionnaires were completed by international event riders (FEI CCI*, CCI**, CIC***) at the Hartpury International Horse Trials, UK, to establish the prevalence of riders competing with pain. 96% of international event riders competed while experiencing pain, 76% of riders stated that this pain was in the neck, upper back or shoulders. All female riders reported pain, giving a significant correlation between gender and pain (X=-0.479, P=0.006). 55% of riders felt their pain affected their riding performance, giving an odds ratio of 1.14, compared to those riders who felt their pain did not effect their performance. Pain was perceived to influence performance by affecting fatigue, their concentration, and anxiety levels. 96% of riders reporting pain used medication to alleviate their symptoms. This high incidence of international event riders who compete with pain, particularly back pain, could be problematic given the longevity of a rider’s career, which can span over four decades and could potentially increase the risk of a serious or fatal fall in the cross-country phase. This research reports rider’s perceptions and self-reported pain and management options, which may affect the data. Further research is needed to establish the causes of back pain and appropriate management strategies.

Prediction of Persistent Post-Concussion Symptoms after Mild Traumatic Brain Injury

Persistent post-concussion symptoms (PPCS) occur frequently after mild traumatic brain injury (mTBI). The identification of patients at risk for poor outcome remains challenging because valid prediction models are missing. The objectives of the current study were to assess the quality and clinical value of prediction models for PPCS and to develop a new model based on the synthesis of existing models and addition of complaints at the emergency department (ED). Patients with mTBI (Glasgow Coma Scale score 13-15) were recruited prospectively from three Dutch level I trauma centers between 2013 and 2015 in the UPFRONT study. PPCS were assessed using the Head Injury Severity Checklist at six months post-injury. Two prediction models (Stulemeijer 2008; Cnossen 2017) were examined for calibration and discrimination. The final model comprised variables of existing models with the addition of headache, nausea/vomiting, and neck pain at ED, using logistic regression and bootstrap validation. Overall, 591 patients (mean age 51years, 41% female) were included; PPCS developed in 241 (41%). Existing models performed poorly at external validation (area under the curve [AUC]: 0.57-0.64). The newly developed model included female sex (odds ratio [OR] 1.48, 95% confidence interval [CI] [1.01-2.18]), neck pain (OR 2.58, [1.39-4.78]), two-week post-concussion symptoms (OR 4.89, [3.19-7.49]) and two-week post-traumatic stress (OR 2.98, [1.88-4.73]) as significant predictors. Discrimination of this model was adequate (AUC after bootstrap validation: 0.75). Existing prediction models for PPCS perform poorly. A new model performs reasonably with predictive factors already discernible at ED warranting further external validation. Prediction research in mTBI should be improved by standardizing definitions and data collection and by using sound methodology.

Return to Pre-Injury Work Following Mild Traumatic Brain Injury

Objective: Adults are at risk for unemployment following a moderate-severe traumatic brain injury (TBI). Less is known about employment patterns following mild TBI. This study aims to examine patterns of return to pre-injury job in adults following mild TBI over a 12-month post injury period, and to investigate factors associated with return to work. Methods: It is a prospective longitudinal study of 205 adults (aged ≥16 years at injury) identified as part of a larger population-based incidence study in the Waikato, New Zealand. In-person assessments were completed at baseline (within 14 days) and 1-, 6-, and 12-month post-injury. Results: A total of 159 (77.6%) adults returned to their pre-injury job at baseline and 185 (90.2%) returned within 12 months. Of those who did not return to their pre-injury job at baseline (n= 46), younger age at injury (≤30 years,p= .02) and poor overall neurocognitive functioning at 1-month (p= .02) was associated with non-return to pre-injury job at 12 months. Conclusion: In a sample of employed adults, the majority returned to their pre-injury job shortly after injury. Cognitive functioning and younger age at time of injury may be associated with delayed return to work. Interventions to support younger workers may facilitate their return to work.

Risk factors for recurrent neurotrauma: a population-based study in Southeastern Michigan

INTRODUCTION

Studies have shown an increased risk of traumatic brain injury (TBI) for individuals who suffer an initial TBI. The current study hypothesized that individuals with recurrent neurotrauma would originate from populations considered 'vulnerable', i.e. low income and/or with psychiatric comorbidities.

METHODS

Data from the Michigan State Inpatient Database from 2006 to 2014 for the Detroit metropolitan area enlisted a study population of 50 744 patients with neurotrauma. Binary logistic regression was used to assess risk factors associated with admission for subsequent neurotrauma compared with single neurotrauma admission.

RESULTS

Patients with repeated neurotrauma admissions were similar to those with one-time trauma in terms of age at first admission and neighbourhood income levels. However, patients with repeated neurotrauma admissions were more likely to be male (p < .001) and African-American (p < .001). Comorbid alcohol use and drug use were 39% and 15% less likely to be readmitted with neurotrauma, respectively. Comorbid conditions associated with greater risk of repeat neurotrauma included depression, psychosis, and neurological disorders, increasing risk by 38%, 22%, and 58%, respectively.

CONCLUSION

This study validated the hypothesis that comorbid psychiatric conditions are a significant risk factor for recurrent neurotrauma and validate prior studies showing gender and race as significant risk factors.

Examining the Correlation between Acute Behavioral Manifestations of Concussion and the Underlying Pathophysiology of Chronic Traumatic Encephalopathy: A Pilot Study

Concussion in athletes can contribute to early neuropsychological changes that may be indicative of future neurodegenerative disease. One of the hallmark findings of chronic traumatic encephalopathy is anxiety and impulsive behavior that often develops early in the course of the disease. The behavioral dysfunction can be grouped into a broader category referred to as cognitive disruption. The current gold standard for diagnosing chronic neurodegeneration is post-mortem evaluation of tauopathy to identify neurofibrillary tau tangles in neurons. Few studies, however, have looked at clinical correlations between acute injury and chronic neurodegeneration in terms of behavior. This lack of focus towards translational study has limited advancements towards treatment. In this pilot investigation, the acute cognitive and emotional (anger, impulsivity, and anxiety) affects of concussion in a cohort of collegiate athletes (n = 30) are examined and compared to findings in the post-mortem pathologic features of chronic traumatic encephalopathy. Specifically, the role of the seroternergic system with alpha synuclein and tauopathy staining and the potential for early clinically relevant behavioral and pharmaceutical interventions was investigated. The purpose was to determine if athletes began demonstrating cognitive disruption present in post-mortem evaluation during the acute phase of injury. The acute data was collected via questionnaires within ten days of the athletes’ concussion diagnosis. Results demonstrated that 11 of 30 athletes (36%) scored in a diagnosable range of anxiety post-concussion, and athletes scored above the norm in state-anger (M = 22.9, SD = 9.99), indicating severe emotional disturbance. A limitation is that due to the long time frame from acute injury to the development of neurodegeneration individual athletes cannot be tracked in longevity thus limiting the findings to the realm of correlation. The findings from this pilot study warrant further investigation into the neuropsychological aspects for how to manage concussion and prevent degenerative disease.

Population-based cohort study of the impacts of mild traumatic brain injury in adults four years post-injury

There is increasing evidence that some people can experience persistent symptoms for up to a year following mild TBI. However, few longitudinal studies of mild TBI exist and the longer-term impact remains unclear. The purpose of this study is to determine if there are long-term effects of mild traumatic brain injury (TBI) four-years later. Adults (aged ≥16 years) identified as part of a TBI incidence study who experienced a mild-TBI four-years ago (N = 232) were compared to age-sex matched controls (N = 232). Sociodemographic variables, prior TBI and symptoms were assessed at the time of injury. Four years post-injury participants completed the Rivermead Post-Concussion Symptom Questionnaire, Hospital Anxiety and Depression Scale, Pittsburgh Sleep Quality Index and the Participation Assessment with Recombined Tools. Analysis of covariance was used to compare differences between TBI cases four years post-injury and controls, controlling for prior TBI and depression. A multiple regression model was used to identify the predictors of increased symptoms and reduced participation. The mild-TBI sample experienced significantly increased self-reported cognitive symptoms (F = 19.90, p = <0.01) four years post-injury than controls. There were no differences between the groups for somatic (F = 0.02, p = 0.89) or emotional symptoms (F = 0.31, p = 0.58). Additionally, the mild-TBI group reported significantly poorer community participation across all three domains: productivity (F = 199.07, p = <0.00), social relations (F = 13.93, p = <0.00) and getting out and about (F = 364.69, p = <0.00) compared to controls. A regression model accounting for 41% of the variance in cognitive symptoms in TBI cases revealed a history of TBI, receiving acute medical attention and baseline cognitive symptoms, sleep quality, anxiety and depression were predictive of outcome. The results indicate that whilst somatic and emotional symptoms resolve over time, cognitive symptoms can become persistent and that mild TBI can impact longer-term community participation. Early intervention is needed to reduce the longer-term impact of cognitive symptoms and facilitate participation.

Concussion and the autonomic nervous system: An introduction to the field and the results of a systematic review

BACKGROUND

Recent evidence suggests that autonomic nervous dysfunction may be one of many potential factors contributing to persisting post-concussion symptoms.

OBJECTIVE

This is the first systematic review to explore the impact of concussion on multiple aspects of autonomic nervous system functioning.

METHODS

The methods employed are in compliance with the American Academy of Neurology (AAN) and PRISMA standards. Embase, MEDLINE, PsychINFO, and Science Citation Index literature searches were performed using relevant indexing terms for articles published prior to the end of December 2016. Data extraction was performed by two independent groups, including study quality indicators to determine potential risk for bias according to the 4-tiered classification scheme of the AAN.

RESULTS

Thirty-six articles qualified for inclusion in the analysis. Only three studies (one Class II and two Class IV) did not identify anomalies in measures of ANS functioning in concussed populations.

CONCLUSIONS

The evidence supports the conclusion that it is likely that concussion causes autonomic nervous system anomalies. An awareness of this relationship increases our understanding of the physical impact of concussion, partially explains the overlap of concussion symptoms with other medical conditions, presents opportunities for further research, and has the potential to powerfully inform treatment decisions.