Management of Psychological Complications Following Mild Traumatic Brain Injury

Pre-injury psychiatric history, subacute symptoms and personality traits predict social reintegration at 3-month post-mild traumatic brain injury

BACKGROUND

The purpose of the study was to identify whether the presence of a pre-injury psychiatric history, subacute post-concussive symptoms (PCS) and personality traits were predictive of less favorable social reintegration for 3 months following a mild traumatic brain injury (mTBI).

METHOD

A total of 76 patients with mTBI were included, and the presence of a pre-injury psychiatric history was identified from the medical chart. One-month post-accident, these patients completed the Millon Multiaxial Clinical Inventory, 3rd Edition assessing personality traits and the Rivermead Post-Concussion Symptoms Questionnaire to measure subacute PCS. Social reintegration was measured using the Mayo-Portland Adaptability Inventory, 4th Edition at 3-month post-accident.

RESULTS

The presence of pre-injury psychiatric history, high levels of subacute PCS and Cluster B personality traits such as histrionic and borderline features were significant predictors of social reintegration quality at 3-month post injury.

CONCLUSION

This study provides new insights on cluster B personality traits and its influence on recovery and social reintegration at 3-month post mTBI.

Graded exposure therapy for adults with persistent symptoms after mTBI: A historical comparison study

Fear avoidance behaviour is associated with slow recovery from mild traumatic brain injury (mTBI). This study is a preliminary evaluation of graded exposure therapy (GET), which directly targets fear avoidance behaviour, for reducing post-concussion symptoms (PCS) and disability following mTBI. In a historical comparison design, we compared two groups from independent randomized trials. The GET + UC group (N = 34) received GET (delivered over 16 videoconference sessions) in addition to usual care (UC). The historical comparison group (N = 71) received UC only. PCS severity (Rivermead Post Concussion Symptoms Questionnaire; RPQ) and disability (World Health Organization Disability Assessment Schedule; WHODAS 2.0 12-item) were measured at clinic intake (M = 2.7, SD = 1.1 months after injury) and again at M = 4.9 (SD = 1.1) months after injury. Between-group differences were estimated using linear mixed effects regression, with a sensitivity analysis controlling for injury-to-assessment intervals. The estimated average change on the RPQ was -14.3 in the GET + UC group and -5.3 in the UC group. The estimated average change on the WHODAS was -5.3 in the GET + UC group and -3.2 in the UC group. Between-group differences post-treatment were -5.3 on the RPQ and -1.5 on the WHODAS. Treatment effects were larger in sensitivity analyses. Findings suggest that a randomized controlled trial is warranted.

Adolescents With a High Burden of New-Onset Mood Symptoms After Sport-Related Concussion Benefit From Prescribed Aerobic Exercise, a Secondary Analysis of 2 Randomized Controlled Trials

OBJECTIVE

Approximately 20% of students with sport-related concussion (SRC) report new symptoms of anxiety and depression which may be associated with delayed recovery and increased risk for developing a mood disorder. Early prescribed aerobic exercise facilitates recovery in athletes with concussion-related exercise intolerance. We studied the effect of aerobic exercise treatment on new mood symptoms early after SRC.

DESIGN

Exploratory secondary analysis of 2 randomized controlled trials (RCT).

SETTING

Sports medicine clinics associated with UB (Buffalo, NY), CHOP (Philadelphia, PA), and Boston Children's Hospital (Boston, MA).

PARTICIPANTS

Male and female adolescents (aged 13-18 years) diagnosed with SRC (2-10 days since injury).

INTERVENTIONS

Participants were randomized to individualized targeted heart rate aerobic exercise (n = 102) or to a placebo intervention designed to mimic relative rest (n = 96).

MAIN OUTCOME MEASURES

Incidence of Persisting Post-Concussive Symptoms (PPCS, symptoms ≥28 days).

RESULTS

First RCT recruited from 2016 to 2018 and the second from 2018 to 2020. Of 198 adolescents, 156 (79%) reported a low burden (mean 1.2 ± 1.65/24) while 42 (21%) reported a high burden (mean 9.74 ± 3.70/24) of emotional symptoms before randomization. Intervention hazard ratio for developing PPCS for low burden was 0.767 (95% CI, 0.546-1.079; P = 0.128; β = 0.085) and for high burden was 0.290 (95% CI, 0.123-0.683; P = 0.005; β = 0.732).

CONCLUSIONS

High burden of mood symptoms early after injury increases risk for PPCS, but the sports medicine model of providing early targeted aerobic exercise treatment reduces it. Nonsports medicine clinicians who treat patients with a high burden of new mood symptoms after concussion should consider prescribing aerobic exercise treatment to reduce the risk of PPCS and a mood disorder.

Diagnostic Accuracy of Mental Health Screening Tools After Mild Traumatic Brain Injury

Importance

Mental health disorders are common after mild traumatic brain injury (mTBI) and likely exacerbate postconcussive symptoms and disability. Early detection could improve clinical outcomes, but the accuracy of mental health screening tools in this population has not been well established.

Objective

To determine the diagnostic accuracy of the Patient Health Questionnaire-9 (PHQ-9), Generalizaed Anxiety Disorder-7 (GAD-7), and Primary Care PTSD (Posttramatic Stress Disorder) Screen for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) (PC-PTSD-5) in adults with mTBI.

Design, Setting, and Participants

This diagnostic study was performed as a secondary analysis of a cluster randomized clinical trial. Self-report mental health screening tools (PHQ-9, GAD-7, and PC-PTSD-5) were administered online 12 weeks after mTBI and compared against a structured psychodiagnostic interview (Mini-International Neuropsychiatric Interview for DSM-5 (MINI) over videoconference at the same time. Adults with mTBI (N = 537) were recruited from February 1, 2021, to October 25, 2022.

Main Outcomes and Measures

Presence of a major depressive episode, anxiety disorders, and PTSD were determined by a blinded assessor with the MINI. Diagnostic accuracy statistics were derived for the PHQ-9, GAD-7, and PC-PTSD-5. Findings were disaggregated for participants with and without persistent postconcussion symptoms (PPCS) by International and Statistical Classification of Diseases, Tenth Revision criteria.

Results

Data were available for 499 of 537 trial participants, 278 (55.7%) of whom were female; the mean (SD) age was 38.8 (13.9) years. Each screening questionnaire had strong diagnostic accuracy in the overall sample for optimal cut points (area under the curve [AUC], ≥0.80; sensitivity, 0.55-0.94; specificity, 0.64-0.94). The AUC (difference of 0.01-0.13) and specificity (difference, 5-65 percentage points) were lower in those with PPCS present compared with PPCS absent, but the prevalence of at least 1 mental health disorder was 3 to 5 times higher in patients with PPCS present. The GAD-7 had slightly better performance than the PC-PTSD-5 for detecting PTSD (AUC, 0.85 [95% CI, 0.80-0.89] vs 0.80 [95% CI, 0.72-0.87]). The optimal cutoff on the PHQ-9 was 5 or more symptoms experienced on more than half of days; on the GAD-7, a total score of at least 7.

Conclusions and Relevance

The findings of this diagnostic study suggest that the PHQ-9, GAD-7 and PC-PTSD-5 accurately screen for mental health disorders in patients with mTBI. Future research should corroborate optimal test cutoffs for this population.

Feasibility and Preliminary Effectiveness of an Online Meditation Intervention in Young Adults With Concussion History

CONTEXT

Mindfulness interventions (yoga, meditation) in traumatic brain injury populations show promising improvements in injury outcomes. However, most studies include all injury severities and use in-person, general programming lacking accessibility and specificity to the nuance of concussion. Therefore, this study investigated the feasibility and preliminary effectiveness of an online, concussion-focused meditation intervention among young adults with a concussion history.

DESIGN

Unblinded, single-arm, pilot intervention.

METHODS

Fifteen young adults aged 18 to 30 with a concussion history within the past 5 years completed 10 to 20 minutes per day of online, guided meditations for 6 weeks. Feasibility was assessed using the Feasibility of Intervention Measure. Concussion symptoms were measured using the Rivermead Post-Concussion Symptom Questionnaire, perceived stress the Perceived Stress Scale-10, and mindfulness the Five Facet Mindfulness Questionnaire. Descriptive statistics described the study sample and determined intervention adherence and feasibility. Paired sample t tests were used to examine preintervention/postintervention changes in concussion symptoms, perceived stress, and mindfulness, with descriptive statistics further detailing significant t tests.

RESULTS

Fifteen participants were enrolled, and 12 completed the intervention. The majority completed 5+ days per week of the meditations, and Feasibility of Intervention Measure (17.4 [1.8]) scores indicated high feasibility. Concussion symptom severity significantly decreased after completing the meditation intervention (11.3 [10.3]) compared with before the intervention (24.5 [17.2]; t[11] = 3.0, P = .01). The number of concussion symptoms reported as worse than before their concussion significantly decreased after completing the meditation intervention (2.7 [3.9]) compared with before the intervention (8.0 [5.7]; t[11] = 3.7, P = .004). Postintervention, 83.33% (n = 10) reported lower concussion symptom severity, and 75.00% (n = 9) reported less concussion symptoms as a mild, moderate, or severe problem (ie, worse than before injury).

CONCLUSIONS

Findings suggest positive adherence and feasibility of the meditation intervention, with the majority reporting concussion symptom improvement postintervention. Future research is necessary to expand these pilot findings into a large trial investigating concussion-specific meditation programming.

A Scoping Review on the Use of Non-Invasive Brain Stimulation Techniques for Persistent Post-Concussive Symptoms

BACKGROUND

In the context of managing persistent post-concussive symptoms (PPCS), existing treatments like pharmacotherapy, cognitive behavioral therapy, and physical rehabilitation show only moderate effectiveness. The emergence of neuromodulation techniques in PPCS management has led to debates regarding optimal stimulation parameters and their overall efficacy.

METHODS

this scoping review involved a comprehensive search of PubMed and ScienceDirect databases, focusing on controlled studies examining the therapeutic potential of non-invasive brain stimulation (NIBS) techniques in adults with PPCS.

RESULTS

Among the 940 abstracts screened, only five studies, encompassing 103 patients (12 to 29 per study), met the inclusion criteria. These studies assessed the efficacy of transcranial direct current stimulation (tDCS), or repetitive transcranial magnetic stimulation (rTMS), applied to specific brain regions (i.e., the left dorsolateral pre-frontal cortex (DLPFC) or left motor cortex (M1)) for addressing cognitive and psychological symptoms, headaches, and general PPCSs. The results indicated improvements in cognitive functions with tDCS. In contrast, reductions in headache intensity and depression scores were observed with rTMS, while no significant findings were noted for general symptoms with rTMS.

CONCLUSION

although these pilot studies suggest promise for rTMS and tDCS in PPCS management, further research with larger-scale investigations and standardized protocols is imperative to enhance treatment outcomes for PPCS patients.

Work-related and non-work-related mild traumatic brain injury: Associations with mental health and substance use challenges in a Canadian population-level survey

BACKGROUND

Mild traumatic brain injury (mTBI) can profoundly impact overall health, employment, and family life. Incidence of mTBI in the workplace represents an important subgroup with poorer outcomes. Mental health (MH) and substance use (SU) challenges are a primary correlate of TBI, but are rarely assessed among individuals with a work-related (wr)-mTBI, particularly at a population-level.

OBJECTIVE

This study aimed to assess the association between lifetime wr-mTBI and non-wr-mTBI and the experience of MH and SU challenges.

METHODS

The 2019 Centre for Addiction and Mental Health (CAMH) Monitor is a cross-sectional telephone survey of adults aged≥18 years in Ontario, Canada, employing a stratified (six regions) two-stage (telephone number, respondent) list-assisted random digit dialing probability selection procedure (N = 1792). Adjusting for sociodemographic variables, binary logistic regression was conducted to assess the association between lifetime wr-mTBI and non-wr-mTBI (relative to no TBI) and four outcomes: hazardous use of alcohol and of cannabis, psychological distress, and fair/poor mental health.

RESULTS

Adjusting for sociodemographic variables, non-wr-mTBI demonstrated increased odds of hazardous alcohol (AOR = 2.12, 95% CI = 1.41, 3.19) and cannabis use (AOR = 1.61, 95% CI = 1.05, 2.45), psychological distress (AOR = 1.68, 95% CI = 1.14, 2.49), and fair/poor mental health (AOR = 1.70, 95% CI = 1.11, 2.59). Lifetime wr-mTBI demonstrated increased odds of reporting psychological distress (AOR = 3.40, 95% CI = 1.93, 5.97) and fair/poor mental health (AOR = 2.16, 95% CI = 1.12, 4.19) only.

CONCLUSIONS

Non-wr-mTBI was associated with both MH and SU, whereas wr-mTBI was associated with MH only. MH outcomes were more strongly associated with wr-mTBI than non-wr-mTBI. Physicians, employers, and insurers need to consider the potential association between wr-mTBI and MH, and provide care accordingly.