The INVEST trial: a randomised feasibility trial of psychologically informed vestibular rehabilitation versus current gold standard physiotherapy for people with Persistent Postural Perceptual Dizziness

Feasibility of gamified visual desensitisation for visually-induced dizziness

Visually-induced dizziness (visual vertigo) is a core symptom of Persistent Perceptual Postural Dizziness (PPPD) and occurs in other conditions and general populations. It is difficult to treat and lacks new treatments and research. We incorporated the existing rehabilitation approach of visual desensitisation into an online game environment to enhance control over visual motion and complexity. We report a mixed-methods feasibility trial assessing: Usage and adherence; rehabilitation potential; system usability and enjoyment; relationship with daily dizziness. Participants played online with (intervention, N = 37) or without (control, N = 39) the visual desensitisation component for up to 5-10 min, twice daily for 6 weeks. Dropout was 45%. In the intervention group, N = 17 played for the recommended time while N = 20 played less. Decreases in visual vertigo symptoms, anxiety and depression correlated with playtime for the intervention but not control. System usability was high. Daily symptoms predicted playtime. Qualitative responses broadly supported the gamified approach. The data suggest gamified visual desensitisation is accessible, acceptable and, if adherence challenges can be overcome, could become a useful addition to rehabilitation schedules for visually-induced dizziness and associated anxiety. Further trials are needed.

Comparative effectiveness of non- pharmacological treatments in patients with persistent postural-perceptual dizziness: a systematic review and effect sizes analyses

Introduction

The patho-psychological mechanisms of persistent postural-perceptual dizziness (PPPD) appear to be very complex, and a multimodal, multidisciplinary approach is suggested for treating patients with PPPD. The aim of this review was to provide a comprehensive overview of non-pharmacological treatments and their comparative effectiveness in patients with PPPD.

Methods

Scopus, Web of Science, PsycINFO, Medline, Embase, CINAHL, Cochrane Library and ClinicalTrials.gov were searched in April 2022 with a search update in August 2023. Only randomized controlled trials (RCTs) were included. There was no restrictions regarding publication date. Two reviewers independently identified eligible trials, extracted data, double-checked all extracted information from the included articles and assessed the risk of bias using the Cochrane risk of bias tool. A qualitative synthesis was performed, considering methodological heterogeneity between trials. Finally, an effect size analysis was performed for each treatment comparison. The standardized mean differences (SMD) and their corresponding 95% confidence intervals (95%CI) were calculated for each trial using Review Manager 5.4.

Results

Thirteen RCTs (618 patients with moderate or mild dizziness) out of 1,362 references describing seven different non-pharmacological comparisons were selected. Nine trials included patients with PPPD, and four trials included patients with functional dizziness. The trials used different interventions that were classified as: (1) psychotherapeutic interventions (cognitive behavioral therapy, patient education), (2) physiotherapeutic interventions/training (vestibular rehabilitation, optokinetic stimulation), (3) stimulation procedures (vagus nerve stimulation, transcranial direct current stimulation) and (4) device application (visual desensitization using personalized glasses). However, most of the trials investigated the effects of single interventions, rather than multimodal interdisciplinary treatment of patients with PPPD. The SMD for dizziness handicap and severity was between 0.04 and 0.52 in most trials. In one trial using visual desensitization, the SMD was 1.09 (strong effect on the severity of dizziness) and 1.05 (strong effect on dizziness handicap).

Discussion

Several individual interventions have shown benefits in the treatment of patients with PPPD with small to moderate effects. However, the multimodal treatment or a combination of vestibular rehabilitation with visual desensitization, cognitive behavioral therapy including patient education, and medication support should be further investigated. Future trials should include a large sample size with severe dizziness, and provide a longer follow-up period.

Clinical trial registration

PROSPERO CRD42022320344.

Persistent postural-perceptual dizziness: A functional neuro-otologic disorder

Persistent postural-perceptual dizziness (PPPD) is a functional neuro-otologic disorder that is the most frequent cause of chronic vestibular syndrome. The core vestibular symptoms include dizziness, unsteadiness, and non-spinning vertigo, which are exacerbated by an upright posture or walking, active or passive motion, and exposure to moving or complex visual stimuli. PPPD is mostly precipitated by acute or episodic vestibular diseases; however, its symptoms cannot be accounted for by its precipitants. PPPD is not a diagnosis of exclusion, but may coexist with other structural diseases. Thus, when diagnosing PPPD, the patient's symptoms must be explained by PPPD alone or by PPPD in combination with a structural illness. PPPD is most frequently observed at approximately 50 years of age, with a female predominance. Conventional vestibular tests do not reveal any specific signs of PPPD. However, the head roll-tilt subjective visual vertical test and gaze stability test after exposure to moving visual stimuli may detect the characteristic features of PPPD, that is, somatosensory- and visually-dependent spatial orientation, respectively. Therefore, these tests could be used as diagnostic tools for PPPD. Regarding the pathophysiology of PPPD, neuroimaging studies suggest shifts in interactions among visuo-vestibular, sensorimotor, and emotional networks, where visual inputs dominate over vestibular inputs. Postural control also shifts, leading to the stiffening of the lower body. To treat PPPD, selective serotonin reuptake inhibitors/serotonin noradrenaline reuptake inhibitors, vestibular rehabilitation, and cognitive behavioral therapy are used alone or in combination.

Mental Health Education and Utilization Among Patients with Vestibular Disorders

To explore the receipt of mental health education, assessment, and referrals, and mental health service use among individuals with vestibular disorders. Patients with vestibular disorders living in the US, Australia, Canada, and the UK were surveyed through social media forums. Questionnaires assessed demographics, anxiety (Generalized Anxiety Disorder-7), depression (Center for Epidemiological Studies Depression-10), dizziness (Dizziness Handicap Inventory), and type of professional providing mental health education, assessment, referral, and treatment. The 226 participants were largely White (90%), educated (67% holding an associate's degree or higher) women (88%) with an average age of 45 who self-identified as having chronic vestibular symptoms (78%), as opposed to episodic ones (22%). Fifty-two percent reported never receiving verbal education, written education (69%), mental health assessment (54%), or referral (72%). Participants were more likely to receive mental health treatment in the past if they had received verbal resources and/or referrals from clinicians. The majority of patients with vestibular disorders report that medical professionals have not provided education, mental health assessment, or a mental health referral.

Effectiveness of Telerehabilitation in Dizziness: A Systematic Review with Meta-Analysis

Dizziness can be a debilitating condition with various causes, with at least one episode reported in 17% to 30% of the international adult population. Given the effectiveness of rehabilitation in treating dizziness and the recent advancements in telerehabilitation, this systematic review aims to investigate the effectiveness of telerehabilitation in the treatment of this disorder. The search, conducted across Medline, Cochrane Central Register of Controlled Trials, and PEDro databases, included randomized controlled trials assessing the efficacy of telerehabilitation interventions, delivered synchronously, asynchronously, or via tele-support/monitoring. Primary outcomes focused on dizziness frequency/severity and disability, with secondary outcomes assessing anxiety and depression measures. Seven articles met the eligibility criteria, whereas five articles contributed to the meta-analysis. Significant findings were observed regarding the frequency and severity of dizziness (mean difference of 3.01, p < 0.001), disability (mean difference of -4.25, p < 0.001), and anxiety (standardized mean difference of -0.16, p = 0.02), favoring telerehabilitation. Telerehabilitation shows promise as a treatment for dizziness, aligning with the positive outcomes seen in traditional rehabilitation studies. However, the effectiveness of different telerehabilitation approaches requires further investigation, given the moderate methodological quality and the varied nature of existing methods and programs.

Additional cognitive behavior therapy for persistent postural-perceptual dizziness: a meta-analysis

OBJECTIVE

To investigate whether additional Cognitive Behavior Therapy (CBT) combined with conventional therapy improves outcomes for patients with Persistent Postural-Perceptual Dizziness (PPPD) compared with conventional therapy alone.

METHODS

Two reviewers independently searched PubMed, Embase, Web of Science, Cochrane Library, and ClinicalTrials.gov for relevant Randomized Controlled Trials (RCTs) examining CBT for PPPD which were conducted and published in English from January 2002 to November 2022. RCTs reporting any indicators for assessing corresponding symptoms of PPPD were included, such as Dizziness Handicap Inventory (DHI), Hamilton Anxiety Scale (HAMA), Hamilton Depression Scale (HAMD), Hospital Anxiety and Depression Scale (HADS), and Patient Health Questionnaire-9 (PHQ-9). Two independent reviewers conducted extraction of relevant information and evaluation of risk of bias. The Cochrane Collaboration risk of bias tool version 1.0 was used to evaluate risks and assess the quality of the included studies, and Cochrane Review Manager 5.3 software (RevMan 5.3) was used to perform meta-analyses.

RESULTS

The results of six RCTs indicated that combining additional CBT with conventional therapy significantly improved outcomes for PPPD patients compared with conventional therapy alone, especially in DHI-Total scores (Mean Difference [MD = -8.17], 95% Confidence Interval [95% CI: -10.26, -6.09], p < 0.00001), HAMA scores (MD = -2.76, 95% CI: [-3.57, -1.94], p < 0.00001), GAD-7 scores (MD = -2.50, 95% CI [-3.29, -1.70], p < 0.00001), and PHQ-9 scores (MD = -2.29, 95% CI [-3.04, -1.55], p < 0.00001). Subgroup analysis revealed a significant benefit of additional CBT compared with conventional therapies alone, including Vestibular Rehabilitation Therapy (VRT) (MD = -8.70, 95% CI: [-12.17, -5.22], p < 0.00001), Selective Serotonin Reuptake Inhibitor (SSRI) (with controlled SSRI: MD = -10.70, 95% CI: [-14.97, -6.43], p < 0.00001), and VRT combined with SSRI (MD = -6.08, 95% CI [-9.49, -2.67], p = 0.0005) in DHI-Total scores.

CONCLUSION

Additional CBT combined with conventional therapy may provide additional improvement for patients with PPPD compared with conventional therapy alone. However, more RCTs are needed to support and guide the application of CBT in treating PPPD.

LEVEL OF EVIDENCE

I; Systematic review of RCTs.

Exploring the role of attention towards balance in chronic dizziness: Development of the Balance Vigilance Questionnaire

BACKGROUND AND PURPOSE

Vigilance towards balance has been proposed to underpin various chronic dizziness disorders, including persistent postural-perceptual dizziness (PPPD). The objective of this study was to develop (through patient input) a validated balance-specific measure of vigilance that comprehensively assesses the varied ways in which this construct may manifest.

METHODS

We developed the Balance Vigilance Questionnaire (Balance-VQ) through patient and clinician feedback, designed to assess vigilance towards balance. We then validated the questionnaire in 497 participants consisting of patients diagnosed with chronic dizziness disorders (including 97 individuals diagnosed with PPPD) and healthy controls.

RESULTS

The final six-item Balance-VQ was shown to be a valid and reliable way to assess vigilance towards balance. Scores were significantly higher in individuals diagnosed with PPPD compared to controls. Although scores were also higher in the PPPD group compared to individuals with diagnosed vestibular disorders other than PPPD, Balance-VQ scores did not discriminate between the two groups when confounding factors (including dizziness severity) were controlled for. Scores did, however, independently discriminate between the PPPD group and individuals who experience dizziness in daily life, but who have not been diagnosed with a neuro-otological disorder.

CONCLUSIONS

Our findings confirm that the Balance-VQ is a valid and reliable instrument for assessing vigilance towards balance. As symptom vigilance has been identified as a key risk factor for developing chronic dizziness following acute vestibular symptoms or balance disruption, we recommend using the Balance-VQ as a screening tool in people presenting with such symptoms.

Impact and experiences of vestibular disorders and psychological distress: Qualitative findings from patients, family members and healthcare professionals

INTRODUCTION

People with vestibular disorders frequently experience reduced quality of life and challenges with activities of daily living. Anxiety, depression and cognitive problems often co-present with vestibular disorders and can aggravate symptoms and prolong clinical recovery. We aimed to gain in-depth insights into the impact of vestibular disorders and the contribution of psychological factors by exploring multistakeholder perspectives.

METHODS

Semistructured interviews were conducted between October 2021 and March 2022 with 47 participants in the United Kingdom including: 20 patients (age M = 50.45 ± 13.75; 15 females), nine family members (age M = 61.0 ± 14.10; four females), and 18 healthcare professionals. Data were analysed using framework analysis.

RESULTS

Vestibular disorders impact diverse aspects of patients' lives including work, household chores, socialising, and relationships with family and friends. Being unable to engage in valued activities or fulfil social roles contributes to feelings of grief and frustration, affecting identity, confidence, and autonomy. Anxiety and low mood contribute to negative thought processes, avoidance, and social withdrawal, which can impede clinical recovery through reduced activity levels, and end engagement with treatment. Coping strategies were thought to help empower patients to self-manage their symptoms and regain a sense of control, but these require oversight from healthcare providers.

CONCLUSIONS

Daily activity limitations, social participation restrictions, and psychological distress can interact to impact quality of life, sense of self, and clinical recovery amongst people with vestibular disorders. Information and resources could aid societal awareness of the impact of vestibular disorders and help patients and families feel understood. An individualised and comprehensive approach that concurrently addresses mental, physical, social, and occupational needs is likely to be beneficial.

PATIENT OR PUBLIC CONTRIBUTION

Two group meetings were held at the beginning and end of the study with a patient and public involvement network formed of people with vestibular disorders and family members. These individuals commented on the study aims, interview schedule, participant recruitment practices, and interpretation of the themes identified. Two core patient members were involved at all stages of the research. These individuals contributed to the formulation of the interview schedule, development and application of the coding scheme, development and interpretation of themes, and preparation of the final manuscript.

Cognition in vestibular disorders: state of the field, challenges, and priorities for the future

Vestibular disorders are prevalent and debilitating conditions of the inner ear and brain which affect balance, coordination, and the integration of multisensory inputs. A growing body of research has linked vestibular disorders to cognitive problems, most notably attention, visuospatial perception, spatial memory, and executive function. However, the mechanistic bases of these cognitive sequelae remain poorly defined, and there is a gap between our theoretical understanding of vestibular cognitive dysfunction, and how best to identify and manage this within clinical practice. This article takes stock of these shortcomings and provides recommendations and priorities for healthcare professionals who assess and treat vestibular disorders, and for researchers developing cognitive models and rehabilitation interventions. We highlight the importance of multidisciplinary collaboration for developing and evaluating clinically relevant theoretical models of vestibular cognition, to advance research and treatment.

What's in a Name? Chronic Vestibular Migraine or Persistent Postural Perceptual Dizziness?

Current consensus diagnostic criteria for vestibular migraine (VM) describes this as an episodic disorder. However, a minority of patients report prolonged (>72 h duration) or even persistent VM symptoms, prompting whether a chronic variant of vestibular migraine (CVM) should be introduced to the current classification and how best to define it. Here we summarize current evidence of such a potential chronic variant of VM and critically review proposed definitions for CVM. Potential approaches to establish a diagnostic framework for CVM include (a) following the distinction between episodic and chronic migraine headaches, namely, frequent and/or prolonged episodes of VM (but not persistent vertigo or dizziness) in the context of chronic migraine headaches or (b) daily dizzy spells over more than 6 months that responded well to prophylactic anti-migraine therapy. A key challenge when defining diagnostic criteria for CVM is how to distinguish it from other chronic vestibular syndromes such as motion sickness, persistent postural-perceptual dizziness (PPPD), and mal de débarquement syndrome. Indeed, more than 50% of patients with PPPD and up to 46% with mal de débarquement syndrome fulfil diagnostic criteria for episodic migraine headaches, suggesting these disorders may all lie along a spectrum. We propose that when VM becomes persistent, it is best classified as PPPD but that VM and PPPD are not mutually exclusive, such that patients with PPPD need not have features of VM, and the triggering event for persistent dizziness may be independent of migraine. However, further research is needed to better characterize the spectrum of clinical phenotypes in patients with chronic dizziness, migraine headaches and anxiety, to define whether a chronic variant of VM sufficiently differs from current persistent dizziness definitions.

Fear avoidance beliefs, anxiety, and depression in healthy individuals and persons with vestibular disorders across cultures

Background/introduction

In persons with vestibular disorders, disturbed vestibular input and accompanying dizziness can be associated with anxiety or depression. To avoid dizziness, persons with vestibular disorders can develop mal-adaptive fear avoidance behaviors which can negatively influence daily life functioning. The aims of this study were to (1) document different psychological factors in patients with vestibular disorders and healthy adults across cultures and (2) to assess the convergent validity of the 9-item Vestibular Activities Avoidance Instrument (VAAI), which quantifies fear avoidance beliefs.

Methods

Psychological factors and disability were measured in Dutch-speaking healthy adults and English- and Dutch-speaking persons with vestibular disorders using the VAAI, the Dizziness Handicap Inventory (DHI), the Hospital Anxiety and Depression Scale (HADS) and the Activities-Specific Balance Confidence Scale (ABC). The convergent validity of the VAAI was investigated by performing correlation analyses between the VAAI, the DHI, the HADS, and the ABC.

Results

A total of 151 Dutch-speaking healthy adults, 404 English-speaking participants with vestibular disorders, and 126 Dutch-speaking participants with vestibular disorders were included. Participants with vestibular disorders presented with higher levels of fear avoidance beliefs (VAAI), perceived disability (DHI), anxiety and depression (HADS), and lower confidence during balance activities (ABC) compared to healthy adults. Regarding the convergent validity of the VAAI, there were moderate to strong correlation coefficients (r = 0.39-0.74) between fear avoidance and the DHI, HADS, and ABC in participants with vestibular disorders.

Conclusions

Participants with vestibular disorders report a higher psychological burden compared to healthy adults. These results emphasize the importance of assessing psychological factors in persons with vestibular disorders. In addition, evidence was provided for convergent validity, supporting the VAAI as a valid outcome measure across cultures.

Effectiveness of Vestibular Rehabilitation in Improving Health Status and Balance in Patients with Fibromyalgia Syndrome: A Single-Blind Randomized Controlled Trial

BACKGROUND

Fibromyalgia Syndrome (FMS) is a highly prevalent health problem whose main symptom is widespread pain, although it presents as other manifestations, such as loss of balance, that seem to mainly affect visuo-vestibular information.

OBJECTIVE

to compare the effects of a Vestibular Rehabilitation (VR) program versus those of a Conventional Physical Exercise (CPE) program on the health status of patients with FMS.

METHODS

A single-blind randomized controlled trial was performed. Patients with FMS were randomly assigned to VR or CPE programs. The protocols were performed in 40 min group sessions, twice weekly, for 16 sessions. Perceived health status, static and dynamic balance, verticality perception, confidence in balance, sensitization and kinesiophobia were measured at baseline, post-treatment and at the three-month follow-up and analyzed using an intention-to-treat approach.

RESULTS

Forty-eight subjects were randomly assigned, of whom thirty-five completed the planned VR (n = 19) or CPE (n = 16) program. At the three-month follow-up, there were differences in physical health status measured with the SF-12 (mean = -4.36, SE = 1.88, p = 0.027), balance during walking (mean = 1.90, SE = 0.57, p = 0.002), the perception of verticality in degrees (mean = 3.61, SE = 1.51, p = 0.024) and the anteroposterior position of the center of pressure (mean = -7.88, SE = 2.80, p = 0.009), as well as a decrease in the number of falls (mean = 0.98, SE = 0.44, p = 0.033), favoring the VR group.

CONCLUSIONS

Vestibular Rehabilitation can be as beneficial as conventional exercise in improving the state of health in patients with Fibromyalgia Syndrome, providing additional improvements in physical health status, body balance, the perception of verticality and the number of falls.

Somatic symptom distress and gender moderate the effect of integrative group psychotherapy for functional vertigo on vertigo handicap: A moderation analysis of a randomised controlled trial

OBJECTIVE

Psychotherapeutic treatments for functional vertigo have shown promising results in recent years but it is still to be determined for whom these treatments work best. The aim of this study was to run a moderation analysis to identify which baseline factors may moderate the success of integrative psychotherapeutic group treatment (IPGT) as compared to a self-help group (SHG) active control.

METHODS

Data from 159 patients included in a 16-week randomised controlled trial were analysed. The outcome was vertigo-related handicap at post-treatment and gender, age, baseline somatisation, depression and anxiety were taken as putative moderators.

RESULTS

We found that baseline somatic symptoms (i.e. PHQ-15 score, p = 0.04, ∆R2 = 0.02) and gender (p = 0.04, ∆R2 = 0.02) significantly moderated the effect of treatment type on post-treatment vertigo handicap. Patients with higher PHQ-15 scores at baseline and women reduced their vertigo handicap more in IPGT as compared to in the control condition.

CONCLUSION

A possible explanation for this result is that somatic symptom distress is the central aetiopathogenetic factor of functional vertigo, while depressiveness and anxiety are rather epiphenomena in the sense of comorbidity. Although the results are not entirely consistent, according to some studies, female gender seems to be a favourable predictor of better therapy outcome. Given the high impairment and healthcare costs in those with vertigo/dizziness and psychiatric comorbidity, it is important to effectively treat these patients as early as possible. This study provides a prescriptive tool for practitioners, allowing for more patient-tailored treatment decisions.

Non-pharmacological interventions for persistent postural-perceptual dizziness (PPPD)

BACKGROUND

Persistent postural-perceptual dizziness (PPPD) is a chronic balance disorder, which is characterised by subjective unsteadiness or dizziness that is worse on standing and with visual stimulation. The condition was only recently defined and therefore the prevalence is currently unknown. However, it is likely to include a considerable number of people with chronic balance problems. The symptoms can be debilitating and have a profound impact on quality of life. At present, little is known about the optimal way to treat this condition. A variety of medications may be used, as well as other treatments, such as vestibular rehabilitation.  OBJECTIVES: To assess the benefits and harms of non-pharmacological interventions for persistent postural-perceptual dizziness (PPPD).  SEARCH METHODS: The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 21 November 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs in adults with PPPD, which compared any non-pharmacological intervention with either placebo or no treatment. We excluded studies that did not use the Bárány Society criteria to diagnose PPPD, and studies that followed up participants for less than three months.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were: 1) improvement in vestibular symptoms (assessed as a dichotomous outcome - improved or not improved), 2) change in vestibular symptoms (assessed as a continuous outcome, with a score on a numerical scale) and 3) serious adverse events. Our secondary outcomes were: 4) disease-specific health-related quality of life, 5) generic health-related quality of life and 6) other adverse effects. We considered outcomes reported at three time points: 3 to < 6 months, 6 to ≤ 12 months and > 12 months. We planned to use GRADE to assess the certainty of evidence for each outcome.  MAIN RESULTS: Few randomised controlled trials have been conducted to assess the efficacy of different treatments for PPPD compared to no treatment (or placebo). Of the few studies we identified, only one followed up participants for at least three months, therefore most were not eligible for inclusion in this review.  We identified one study from South Korea that compared the use of transcranial direct current stimulation to a sham procedure in 24 people with PPPD. This is a technique that involves electrical stimulation of the brain with a weak current, through electrodes that are placed onto the scalp. This study provided some information on the occurrence of adverse effects, and also on disease-specific quality of life at three months of follow-up. The other outcomes of interest in this review were not assessed. As this is a single, small study we cannot draw any meaningful conclusions from the numeric results.  AUTHORS' CONCLUSIONS: Further work is necessary to determine whether any non-pharmacological interventions may be effective for the treatment of PPPD and to assess whether they are associated with any potential harms. As this is a chronic disease, future trials should follow up participants for a sufficient period of time to assess whether there is a persisting impact on the severity of the disease, rather than only observing short-term effects.

Management of Psychological Complications Following Mild Traumatic Brain Injury

PURPOSE OF REVIEW

It has been clear for decades that psychological factors often contribute to mild traumatic brain injury (mTBI) outcome, but an emerging literature has begun to clarify which specific factors are important, when, for whom, and how they impact recovery. This review aims to summarize the contemporary evidence on psychological determinants of recovery from mTBI and its implications for clinical management.

RECENT FINDINGS

Comorbid mental health disorders and specific illness beliefs and coping behaviors (e.g., fear avoidance) are associated with worse recovery from mTBI. Proactive assessment and intervention for psychological complications can improve clinical outcomes. Evidence-based treatments for primary mental health disorders are likely also effective for treating mental health disorders after mTBI, and can reduce overall post-concussion symptoms. Broad-spectrum cognitive-behavioral therapy may modestly improve post-concussion symptoms, but tailoring delivery to individual psychological risk factors and/or symptoms may improve its efficacy. Addressing psychological factors in treatments delivered primarily by non-psychologists is a promising and cost-effective approach for enhancing clinical management of mTBI. Recent literature emphasizes a bio-psycho-socio-ecological framework for understanding mTBI recovery and a precision rehabilitation approach to maximize recovery. Integrating psychological principles into rehabilitation and tailoring interventions to specific risk factors may improve clinical management of mTBI.