Novel interdisciplinary intervention, GAIN, vs. enhanced usual care to reduce high levels of post-concussion symptoms in adolescents and young adults 2-6 months post-injury: A randomised trial

How completely are randomized controlled trials of non-pharmacological interventions following concussion reported? A systematic review

PURPOSE

The study aimed to examine the reporting completeness of randomized controlled trials (RCTs) of non-pharmacological interventions following concussion.

METHODS

We searched MEDLINE, Embase, PsycInfo, CINAHL, and Web of Science up to May 2022. Two reviewers independently screened studies and assessed reporting completeness using the Template for Intervention Description and Replication (TIDieR), Consensus on Exercise Reporting Template (CERT), and international Consensus on Therapeutic Exercise aNd Training (i-CONTENT) checklists. Additional information was sought my study authors where reporting was incomplete. Risk of bias (ROB) was assessed with the Cochrane ROB-2 Tool. RCTs examining non-pharmacological interventions following concussion.

RESULTS

We included 89 RCTs (n = 53 high ROB) examining 11 different interventions for concussion: sub-symptom threshold aerobic exercise, cervicovestibular therapy, physical/cognitive rest, vision therapy, education, psychotherapy, hyperbaric oxygen therapy, transcranial magnetic stimulation, blue light therapy, osteopathic manipulation, and head/neck cooling. Median scores were: TIDieR 9/12 (75%; interquartile range (IQR) = 5; range: 5-12), CERT 17/19 (89%; IQR = 2; range: 10-19), and i-CONTENT 6/7 (86%; IQR = 1; range: 5-7). Percentage of studies completely reporting all items was TIDieR 35% (31/89), CERT 24% (5/21), and i-CONTENT 10% (2/21). Studies were more completely reported after publication of TIDieR (t87 = 2.08; p = 0.04) and CERT (t19 = 2.72; p = 0.01). Reporting completeness was not strongly associated with journal impact factor (TIDieR: rs = 0.27; p = 0.01; CERT: rs = -0.44; p = 0.06; i-CONTENT: rs = -0.17; p = 0.48) or ROB (TIDieR: rs = 0.11; p = 0.31; CERT: rs = 0.04; p = 0.86; i-CONTENT: rs = 0.12; p = 0.60).

CONCLUSION

RCTs of non-pharmacological interventions following concussion demonstrate moderate to good reporting completeness, but are often missing key components, particularly modifications, motivational strategies, and qualified supervisor. Reporting completeness improved after TIDieR and CERT publication, but publication in highly cited journals and low ROB do not guarantee reporting completeness.

Serum neurofilament light chain, inflammatory markers, and kynurenine metabolites in patients with persistent post-concussion symptoms: A cohort study

BACKGROUND

Concussion leads to persistent post-concussion symptoms (PPCS) in up to one-third of those affected. While previous research has linked the initial trauma to elevated serum levels of neurofilament light chain (NFL), inflammatory markers, and neurotoxic metabolites within the kynurenine pathway, few studies have explored their relevance in PPCS. This study aims to investigate these biomarkers in PPCS patients, elucidating their relevance in the prolonged phase of concussion.

METHODS

Serum samples from 86 PPCS individuals aged 18-30 years, 2-6 months post-trauma were analyzed, with 54 providing follow-up samples after seven months. NFL was measured using single-molecule array (Simoa) technology, 13 inflammatory markers via a Luminex immunoassay, and five kynurenine metabolites using liquid chromatography-mass spectrometry. A control group of 120 healthy anonymous blood donors was recruited for comparison.

RESULTS

No significant NFL differences were found in PPCS participants compared with healthy individuals (p = 0.22). Intriguingly, a subset (9.3%) of PPCS participants initially exhibited abnormally high NFL levels (>9.7 pg/mL), which normalized upon follow-up (p = 0.032). Additionally, serum levels of the inflammatory markers, monocyte chemoattractant protein-1 (MCP-1/CCL2), and eotaxin-1/CCL11 were 25-40% lower than in healthy individuals (p ≤ 0.001). As hypothesized, PPCS participants exhibited a 22% reduction in the ratio of kynurenic acid to quinolinic acid (neuroprotective index) (p < 0.0001), indicating a shift towards the formation of neurotoxic metabolites.

CONCLUSION

NFL may serve as a biomarker to monitor recovery, and future studies should investigate the potential therapeutic benefits of modulating the kynurenine pathway to improve PPCS.

Multidisciplinary care for patients with persistent symptoms following concussion: a systematic review

PURPOSE

To systematically characterize and assess the effectiveness of multidisciplinary care for patients with persistent post-concussion symptoms (PPCS).

MATERIALS AND METHODS

Only studies describing multidisciplinary treatment, defined as intervention provided by no less than 2 healthcare disciplines, each with independent scopes of practice, for patients with PPCS were considered.

RESULTS

A total of 8 of the 1357 studies identified were included. The studies were comprised of heterogenous patient populations, care delivery systems, healthcare providers, treatment approaches, and outcomes.

CONCLUSIONS

Findings suggest multidisciplinary care, using a needs-based approach with individual- or group-based interventions, may be more beneficial than usual care to; 1) immediately reduce concussion-related symptom complaints and improve mood and quality of life in adolescents following sports-related concussion (SRC) and, 2) may produce immediate and lasting improvements in symptom complaints of young, primarily female, adults following a non-SRC. Future studies should clearly describe the decision-making processes used to deliver care through a needs-based approach and prioritize the inclusion of objective, performance-based measures to assess outcomes.

Serum calcitonin gene-related peptide in patients with persistent post-concussion symptoms, including headache: a cohort study

BACKGROUND

Calcitonin gene-related peptide (CGRP) plays an important role in migraine pathophysiology, and post-traumatic headache (PTH) frequently presents with migraine-like features. Despite several clinical similarities, few studies have explored CGRP in PTH and concussion. This study investigates serum CGRP levels in patients with persistent post-concussion symptoms (PPCS), including PTH.

METHODS

This cohort study was based on serum samples from individuals aged 18-30 years with PPCS who participated in a previously published randomized controlled trial of a non-pharmacological intervention. The primary outcome was serum CGRP concentrations, determined at baseline before randomization and at follow-up 7 months later, using an enzyme-linked immunosorbent assay (ELISA). CGRP levels at baseline were compared with healthy anonymous blood donors in the same age group.

RESULTS

Baseline serum samples were collected from 86 participants with PPCS. The participants were most often female (78%) and migraine-like headache was the most frequent headache phenotype (74%). Serum CGRP levels were higher in participants with PPCS than in 120 healthy individuals (median: 158.5 pg/mL vs. 76.3 pg/mL, p = 0.050). A stratified analysis revealed that females with PPCS had a fivefold higher median than healthy females (166.3 pg/mL vs. 32.1 pg/mL, p = 0.0006), while no differences were observed in males (p = 0.83). At follow-up, CGRP levels decreased with a median change of  - 1.3 pg/mL (95% confidence interval:  - 17.6-0, p = 0.024).

DISCUSSION

Elevated serum levels of CGRP in patients with PPCS and a decrease over time suggest an involvement of CGRP in PTH/PPCS. If confirmed in other studies, it could pave the way for CGRP-targeted therapies, which could have clinical significance.

Multidisciplinary interventions increase weekly working hours and quality of life in persons with post-concussion syndrome

OBJECTIVES

To improve labor market attachment, general health and quality of life in persons suffering from post-concussion syndrome. Labor market attachment often changes after mTBI, and especially in persons suffering from post-concussion syndrome, and constitutes a huge societal burden.

METHODS

Eighty-two adults with persistent post-concussion syndrome participated in this single-center and uncontrolled interventional efficacy open-label investigation. The primary endpoint was to increase weekly working hours. Outcome measures ranged from self-reported cognitive symptoms to objective performance testing. Multidisciplinary interventions were used to reduce symptoms of fatigue, stress, pain, oculomotor malfunction, and sensitivity to both sound and light.

RESULTS

Workhours improved from median 0 to 6 hours (p = 0.00002). Several significant improvements were observed in quality of life measured by the SF-36. General fatigue measured by the MFI-20 was reduced (p < 0.0001), and symptoms of depression were reduced (p < 0.0001). The COPM results were improved for task completion satisfaction and for ability to perform a task (p < 0.0001). Reading speed, and performances in the Groffman Visual Tracing Test and the King-Devick Test, all improved (p < 0.01). The intervention did not reduce perception of pain intensity (p = 0.11).

CONCLUSION

After the intervention, participants increased weekly workhours and improved in many aspects of life - including quality of life, performance in everyday activities, fatigue and depression. Perception of pain intensity was not improved.

Examining the interdisciplinary approach for treatment of persistent post-concussion symptoms in adults: a systematic review

BACKGROUND

The objective of this review is to examine the evidence for the interdisciplinary approach in treatment of persistent post-concussion symptoms in adults.

METHODS

This systematic literature search was undertaken according to the Preferred Reporting Items for Systematic and Meta-Analysis (PRISMA) guidelines. Five electronic databases were searched: CINAHL, Informit, ProQuest, PubMed and Scopus. After screening and quality assessment, the review included six studies published in English and peer-reviewed journals, between 2011 and 2021 to return contemporary evidence.

RESULTS

The results revealed that there was significant variation between measures used and the timing of the pre- and post-treatment assessment. The studies found an interdisciplinary approach to be beneficial, however, the challenges of inherent heterogeneity, lack of clarity for definitions and diagnosis, and mixed results were apparent. The interdisciplinary interventions applied in all identified studies were found to reduce post-concussion symptoms across the symptom subtypes: headache/migraine, vestibular, cognitive, ocular motor and anxiety/mood.

CONCLUSIONS

The results demonstrated evidence for a reduction in persistent post-concussion symptoms following interdisciplinary intervention. This evidence will inform health services, clinicians, sports administrators and researchers with regard to concussion clinic and rehabilitation team design and service delivery.

Association of Posttraumatic Headache With Symptom Burden After Concussion in Children

Importance

Headache is the most common symptom after pediatric concussion.

Objectives

To examine whether posttraumatic headache phenotype is associated with symptom burden and quality of life 3 months after concussion.

Design, Setting, and Participants

This was a secondary analysis of the Advancing Concussion Assessment in Pediatrics (A-CAP) prospective cohort study, conducted September 2016 to July 2019 at 5 Pediatric Emergency Research Canada (PERC) network emergency departments. Children aged 8.0-16.99 years presenting with acute (<48 hours) concussion or orthopedic injury (OI) were included. Data were analyzed from April to December 2022.

Exposure

Posttraumatic headache was classified as migraine or nonmigraine headache, or no headache, using modified International Classification of Headache Disorders, 3rd edition, diagnostic criteria based on self-reported symptoms collected within 10 days of injury.

Main Outcomes and Measures

Self-reported postconcussion symptoms and quality-of-life were measured at 3 months after concussion using the validated Health and Behavior Inventory (HBI) and Pediatric Quality of Life Inventory-Version 4.0 (PedsQL-4.0). An initial multiple imputation approach was used to minimize potential biases due to missing data. Multivariable linear regression evaluated the association between headache phenotype and outcomes compared with the Predicting and Preventing Postconcussive Problems in Pediatrics (5P) clinical risk score and other covariates and confounders. Reliable change analyses examined clinical significance of findings.

Results

Of 967 enrolled children, 928 (median [IQR] age, 12.2 [10.5 to 14.3] years; 383 [41.3%] female) were included in analyses. HBI total score (adjusted) was significantly higher for children with migraine than children without headache (estimated mean difference [EMD], 3.36; 95% CI, 1.13 to 5.60) and children with OI (EMD, 3.10; 95% CI, 0.75 to 6.62), but not children with nonmigraine headache (EMD, 1.93; 95% CI, -0.33 to 4.19). Children with migraine were more likely to report reliable increases in total symptoms (odds ratio [OR], 2.13; 95% CI, 1.02 to 4.45) and somatic symptoms (OR, 2.70; 95% CI, 1.29 to 5.68) than those without headache. PedsQL-4.0 subscale scores were significantly lower for children with migraine than those without headache only for physical functioning (EMD, -4.67; 95% CI, -7.86 to -1.48).

Conclusions and Relevance

In this cohort study of children with concussion or OI, those with posttraumatic migraine symptoms after concussion had higher symptom burden and lower quality of life 3 months after injury than those with nonmigraine headache. Children without posttraumatic headache reported the lowest symptom burden and highest quality of life, comparable with children with OI. Further research is warranted to determine effective treatment strategies that consider headache phenotype.

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.

A Systematic Review of Treatments of Post-Concussion Symptoms

Approximately 10−20% of patients who have sustained a mild Traumatic Brain Injury (mTBI) show persistent post-concussion symptoms (PCS). This review aims to summarize the level of evidence concerning interventions for PCS. Following the PRISMA guidelines, we conducted a systematic review regarding interventions for PCS post-mTBI until August 2021 using the Medline, Cochrane, and Embase databases. Inclusion criteria were the following: (1) intervention focusing on PCS after mTBI, (2) presence of a control group, and (3) adult patients (≥18 y.o). Quality assessment was determined using the Incog recommendation level, and the risk of bias was assessed using the revised Cochrane risk-of-bias tool. We first selected 104 full-text articles. Finally, 55 studies were retained, including 35 that obtained the highest level of evidence. The risk of bias was high in 22 out of 55 studies. Cognitive training, psycho-education, cognitive behavioral therapy, and graded return to physical activity demonstrated some effectiveness on persistent PCS. However, there is limited evidence of the beneficial effect of Methylphenidate. Oculomotor rehabilitation, light therapy, and headache management using repetitive transcranial magnetic stimulation seem effective regarding somatic complaints and sleep disorders. The preventive effect of early (<3 months) interventions remains up for debate. Despite its limitations, the results of the present review should encourage clinicians to propose a tailored treatment to patients according to the type and severity of PCS and could encourage further research with larger groups.

Adolescent and parent experiences with Tele-Active Rehabilitation for concussion: an exploratory qualitative study

PURPOSE

To explore the experiences of adolescents with concussion and their parents who participated in a novel remotely delivered Tele-Active Rehabilitation (Tele-AR) intervention involving sub-symptom threshold exercise, education, and support. Specifically, we aimed to elicit perspectives regarding the remote delivery approach, valued aspects of the program, and perceived benefits of the intervention.

METHODS

This qualitative study took place within the context of a larger mixed-methods project exploring the feasibility of the Tele-AR intervention. A descriptive qualitative design was utilized. Semi-structured interviews were conducted with adolescents (n = 3; ages 14-17 years) with concussion and one of their parents (n = 3) within one week of completing the six-week Tele-AR intervention. Data were analyzed using thematic analysis.

RESULTS

Four themes were identified that capture participant experiences in the intervention: (1) Enabling access to active rehabilitation; (2) Focusing on individual needs; (3) Learning to take responsibility for recovery; and (4) Convenience and comfort of engaging in rehabilitation from home.

CONCLUSIONS

A small sample of 3 adolescents with concussion and their parents were satisfied with the Tele-AR intervention and appreciated the convenience and comfort of engaging in rehabilitation from home, which facilitated adolescents taking responsibility for their own recovery. Findings support continued study of Tele-AR, which may be an accessible intervention to facilitate recovery in adolescents with concussion.

Interdisciplinary intervention (GAIN) for adults with post-concussion symptoms: a study protocol for a stepped-wedge cluster randomised trial

Background

Persistent post-concussion symptoms (PCS) are associated with prolonged disability, reduced health-related quality of life and reduced workability. At present, no strong evidence for treatments for people with persistent PCS exists. Our research group developed a novel intervention, “Get going After concussIoN (GAIN)”, that incorporates multiple evidence-based strategies including prescribed exercise, cognitive behavioural therapy, and gradual return to activity advice. In a previous randomised trial, GAIN provided in a hospital setting was effective in reducing symptoms in 15–30-year-olds with PCS 2–6 months post-injury. In the current study, we describe the protocol for a trial designed to test the effectiveness of GAIN in a larger municipality setting. Additionally, we test the intervention within a broader age group and evaluate a broader range of outcomes. The primary hypothesis is that participants allocated to enhanced usual care plus GAIN report a higher reduction in PCS 3 months post-intervention compared to participants allocated to enhanced usual care only.

Methods

The study is a stepped-wedge cluster-randomised trial with five clusters. The 8-week interdisciplinary GAIN program will be rolled out to clusters in 3-month intervals. Power calculation yield at least 180 participants to be enrolled. Primary outcome is mean change in PCS measured by the Rivermead Post-Concussion Symptoms Questionnaire from enrolment to 3 months after end of treatment. Secondary outcomes include participation in and satisfaction with everyday activities, labour market attachment and other behavioural measures. Self-reported outcomes are measured at baseline, by end of treatment and at 3, 6, and 18 months after end of treatment. Registry-based outcomes are measured up to 36 months after concussion.

Discussion

The trial will provide important information concerning the effectiveness of the GAIN intervention in a municipality setting. Furthermore, it will provide knowledge of possible barriers and facilitators that may be relevant for future implementation of GAIN in different settings.

Trial registration

The current GAIN trial is registered in ClinicalTrials.gov (study identifier: NCT04798885) on 20 October 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06572-7.

Tele-Active Rehabilitation for adolescents with concussion: a feasibility study

Objectives

Active rehabilitation involving subsymptom threshold exercise and education/support promotes recovery among adolescents with concussion, but is typically delivered in-person, which limits accessibility. This study explored the feasibility of a remotely delivered Tele-Active Rehabilitation (Tele-AR) intervention for adolescents with concussion.

Methods

A precase–postcase series design was used. Three adolescents (ages 14–17 years) experiencing postconcussion symptoms ≥2 weeks postinjury participated with a parent. The Tele-AR intervention was a 6-week programme supervised by a rehabilitation clinician through weekly videoconferencing appointments and included (1) aerobic exercise, (2) coordination drills and (3) comprehensive education and support. Feasibility indicators included rates of recruitment, retention, adherence, as well as adolescent and parent ratings of technology usability using an adapted Telehealth Usability Questionnaire and satisfaction using the Client Satisfaction Questionnaire-8. Prechanges to postchanges in postconcussion symptoms, illness perceptions, and occupational performance and satisfaction were also assessed.

Results

Rates of recruitment (n=3/4) and retention (n=3/3) achieved success criteria. Adherence was high among all participants (77%–100%), and there were no adverse events. Participant ratings of technology usability and satisfaction approached 90%. All participants reported improvements in postconcussion symptoms and illness perception. Clinically significant positive changes were also observed in occupational performance and satisfaction.

Conclusions

The Tele-AR intervention appears feasible in a small group of adolescents with concussion, and positive changes were observed in postconcussion symptoms, illness perception and occupational performance. Further study is warranted to evaluate the efficacy of this approach, which may enable access to care that supports recovery in adolescents with concussion.

Characterization of persistent post-traumatic headache and management strategies in adolescents and young adults following mild traumatic brain injury

Characteristics of persistent post-traumatic headache (PTH) in young individuals are poorly known leading to diagnostic problems and diverse management. We aimed to describe headache phenotypes and self-reported management strategies in young individuals with PTH following mild traumatic brain injury (mTBI). A comprehensive structured questionnaire was used to evaluate headache phenotypes/characteristics and management strategies to relieve headache in 107, 15–30-year-old individuals with PTH. Around 4 months post-injury, migraine-like headache in combination with tension-type like headache (40%) was the most commonly encountered headache phenotype followed by migraine-like headache (36%). Around 50% reported aura-like symptoms before/during the headache attack. Medication-overuse headache was diagnosed in 10%. Stress, sleep disturbances, and bright lights were the most common trigger factors. More than 80% reported that their headache was worsened by work-related activity and alleviated by rest/lying down. Simple analgesics were commonly used (88%) whereas prophylactic drugs were rarely used (5%). Bedrest and physiotherapy were also commonly used as management strategies by 56% and 34% of the participants, respectively. In conclusion, most young individuals with PTH after mTBI presented with combined migraine-like and tension-type-like headache followed by migraine-like headache, only. Preventive headache medication was rarely used, while simple analgesics and bedrest were commonly used for short-term headache relief.

Neuropsychiatric Treatment for Mild Traumatic Brain Injury: Nonpharmacological Approaches

Postconcussive symptoms following mild traumatic brain injury (mTBI)/concussion are common, disabling, and challenging to manage. Patients can experience a range of symptoms (e.g., mood disturbance, headaches, insomnia, vestibular symptoms, and cognitive dysfunction), and neuropsychiatric management relies heavily on nonpharmacological and multidisciplinary approaches. This article presents an overview of current nonpharmacological strategies for postconcussive symptoms including psychoeducation; psychotherapy; vestibular, visual, and physical therapies; cognitive rehabilitation; as well as more novel approaches, such as neuromodulation. Ultimately, treatment and management of mTBI should begin early with appropriate psychoeducation/counseling, and be tailored based on core symptoms and individual goals.

Self-Rated Executive Function and Health-Related Quality of Life in Young Adults With Persistent Post-Concussion Symptoms: A Cross-Sectional Study

OBJECTIVE

To assess self-reported executive dysfunction in young adult patients with persistent post-concussion symptoms (PCS) 2-6 months post-injury, and the association with self-reported Health-Related Quality of Life (HRQoL).

METHOD

This cross-sectional study carried out in a hospital setting was a secondary analysis of data from a separate randomized trial testing the effect of a novel intervention, "Get going After concussIoN " (GAIN), for persistent PCS. Patients (18-30 years) were recruited from a clinical cohort of patients with a hospital diagnosis of concussion or referred by primary care physicians. Main measures were The Behaviour Rating Inventory of Executive Function-Adult Version providing two index scores, that is, the Metacognitive Index (MI) and the Behavioural Regulation Index (BRI), and the Quality of Life after Brain Injury-Overall Scale.

RESULTS

Compared with normative data, patients had elevated scores (i.e., worse functioning) on both the MI and the BRI. In linear regression analysis, the MI score, but not the BRI score, was negatively associated with self-reported HRQoL (MI: slope = -.27, 95% confidence interval, CI [-.53, -.02], p = .03; BRI: slope = -.19, 95% CI [-.49, .13], p = .24), suggesting a positive association of subjective executive dysfunction and lower HRQoL. However, the association was attenuated after adjustment for self-reported psychological distress (MI: slope = -.09, 95% CI [-.34, .17], p = .51).

CONCLUSION

Self-reported executive dysfunction is common in young adult patients with persistent PCS, but not strongly associated with decreased HRQoL after adjusting for concurrent psychological distress.

Nonpharmacological Treatment of Persistent Postconcussion Symptoms in Adults: A Systematic Review and Meta-analysis and Guideline Recommendation

IMPORTANCE

Persistent (>4 weeks) postconcussion symptoms (PPCS) are challenging for both patients and clinicians. There is uncertainty about the effect of commonly applied nonpharmacological treatments for the management of PPCS.

OBJECTIVE

To systematically assess and summarize evidence for outcomes related to 7 nonpharmacological interventions for PPCS in adults (aged >18 years) and provide recommendations for clinical practice.

DATA SOURCES

Systematic literature searches were performed via Embase, MEDLINE, PsycINFO, CINAHL, PEDro, OTseeker, and Cochrane Reviews (via MEDLINE and Embase) from earliest possible publication year to March 3, 2020. The literature was searched for prior systematic reviews and primary studies. To be included, studies had to be intervention studies with a control group and focus on PPCS.

STUDY SELECTION

A multidisciplinary guideline panel selected interventions based on frequency of use and need for decision support among clinicians, including early information and advice, graded physical exercise, vestibular rehabilitation, manual treatment of neck and back, oculomotor vision treatment, psychological treatment, and interdisciplinary coordinated rehabilitative treatment. To be included, studies had to be intervention studies within the areas of the predefined clinical questions, include a control group, and focus on symptoms after concussion or mild traumatic brain injury.

DATA EXTRACTION AND SYNTHESIS

Extraction was performed independently by multiple observers. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used for data abstraction and data quality assessment. Included studies were assessed using the Assessment of Multiple Systematic Reviews (AMSTAR) tool and the Cochrane Risk of Bias (randomized clinical trials) tool. Meta-analysis was performed for all interventions where possible. Random-effects models were used to calculate pooled estimates of effects. The level and certainty of evidence was rated and recommendations formulated according to the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework.

MAIN OUTCOMES AND MEASURES

All outcomes were planned before data collection began according to a specified protocol. The primary outcomes were the collective burden of PPCS and another outcome reflecting the focus of a particular intervention (eg, physical functioning after graded exercise intervention).

RESULTS

Eleven systematic reviews were identified but did not contribute any primary studies; 19 randomized clinical trials comprising 2007 participants (1064 women [53.0%]) were separately identified and included. Evidence for the 7 interventions ranged from no evidence meeting the inclusion criteria to very low and low levels of evidence. Recommendations were weak for early information and advice, graded physical exercise, vestibular rehabilitation, manual treatment of the neck and back, psychological treatment, and interdisciplinary coordinated rehabilitative treatment. No relevant evidence was identified for oculomotor vision treatment, so the panel provided a good clinical practice recommendation based on consensus.

CONCLUSIONS AND RELEVANCE

Based on very low to low certainty of evidence or based on consensus, the guideline panel found weak scientific support for commonly applied nonpharmacological interventions to treat PPCS. Results align with recommendations in international guidelines. Intensified research into all types of intervention for PPCS is needed.

Attachment and symptom reporting in adolescents and young adults after a concussion

BACKGROUND

The incidence of hospital-treated concussion is 100-300/100,000 person years. Reporting of long-lasting post-concussion symptoms (PCS) is estimated at 5-15%. Attachment insecurity is a potential vulnerability factor for physical illness and poorer disease outcomes in general. This study aimed to explore associations between attachment insecurity and PCS in young people sustaining a concussion.

METHODS

This cross-sectional study was embedded in a cohort of 15-30-year-old patients (n = 3080) 3 months after sustaining a concussion. Data were obtained from a database and questionnaires. PCS were measured by the Rivermead Post-Concussion Symptoms Questionnaire and attachment dimensions (anxiety and avoidance) by the Experiences in Close Relationships-Relationship Structures Questionnaire. Multiple linear regression models were performed to investigate the association between the attachment dimensions and PCS with adjustment for demographic, injury-related and psychological factors and with additional testing for interaction between the attachment dimensions.

RESULTS

In the final study sample, comprising 973 patients (31.6%), we found an interaction between the attachment dimensions. Hence, the effect of attachment anxiety on PCS was statistically insignificant at low avoidance (25th percentile) but significant at high avoidance (75th percentile, β = 0.64 (95%CI: 0.02; 1.26)), whereas the effect of attachment avoidance was significant regardless of level of attachment anxiety (25th percentile, β = 1.09 (95%CI: 0.18; 2.01); 75th percentile, β = 2.71 (95%CI: 1.80; 3.61)).

CONCLUSION

Attachment insecurity, especially characterised by high avoidance in combination with high anxiety, also called fearful attachment, is associated with PCS. Considering the attachment perspective can potentially improve health care for this patient group.

Improving Outcomes for Work-Related Concussions: A Mental Health Screening and Brief Therapy Model

OBJECTIVE

This study assessed the efficacy of a neurocognitive screening evaluation and brief therapy model to improve RTW outcomes for workers who experienced mild head injuries.

METHODS

Patients referred were evaluated using a neurocognitive and psychological screening battery. Work-focused cognitive behavioral therapy was provided when appropriate, addressing the role of negative emotional adjustment and functional sleep disturbance in prolonging recovery.

RESULTS

Average time to RTW was 7 weeks post-evaluation, despite workers being off an average of 10 months between injury and referral dates. Overall, 99% were released to full-duty work without restrictions or accommodations.

CONCLUSIONS

This study demonstrates the favorable outcomes achieved via a structured, clinically driven program for workers who experience head-involved injuries, validating previous research on the importance of recognizing the role of psychological factors in prolonging concussion recovery.

The Role of Active Rehabilitation in Concussion Management: A Systematic Review and Meta-analysis

PURPOSE

This study aimed to conduct a systematic review and meta-analysis of active rehabilitation on concussion management. We also examined moderator variables that may contribute to differences across studies: symptom scale, physical activity type, time of injury to recruitment, and mechanism of injury.

METHODS

The standardized effect size of physical activity on concussion management was computed for 23 studies (29 effect sizes). Effect sizes were coded as positive when studies reported an improvement in symptom scores, which was represented by a decrease in postconcussive symptom scores.

RESULTS

The overall effect size of physical activity on concussion recovery was large and positive (g = 1.03). Subthreshold aerobic activity provided the largest effect size (g = 1.71), whereas multimodal interventions had a moderate effect size (g = 0.70). All other moderator variables produced positive effect sizes ranging from g = 0.59 to g = 1.46.

CONCLUSIONS

This systematic review and meta-analysis demonstrates that current evidence supports the notion that physical activity is beneficial in decreasing postconcussive symptoms in both the acute and chronic phases after concussion. The results indicate that unimodal subthreshold aerobic activity may be the best course of action compared with multimodal interventions. Despite this growing body of evidence, additional research is needed to determine the optimal intensity, duration, and time to initiation of aerobic exercise after concussion.

Microstructural changes in the brain after long-term post-concussion symptoms: A randomized trial

A recent randomized controlled trial in young patients with long-term post-concussion symptoms showed that a novel behavioral intervention "Get going After concussIoN" is superior to enhanced usual care in terms of symptom reduction. It is unknown whether these interventional effects are associated with microstructural brain changes. The aim of this study was to examine whether diffusion-weighted MRI indices, which are sensitive to the interactions between cellular structures and water molecules' Brownian motion, respond differently to the interventions of the above-mentioned trial and whether such differences correlate with the improvement of post-concussion symptoms. Twenty-three patients from the intervention group (mean age 22.8, 18 females) and 19 patients from the control group (enhanced usual care) (mean age 23.9, 14 females) were enrolled. The primary outcome measure was the mean kurtosis tensor, which is sensitive to the microscopic complexity of brain tissue. The mean kurtosis tensor was significantly increased in the intervention group (p = 0.003) in the corpus callosum but not in the thalamus (p = 0.78) and the hippocampus (p = 0.34). An increase in mean kurtosis tensor in the corpus callosum tended to be associated with a reduction in symptoms, but this association did not reach significance (p = 0.059). Changes in diffusion tensor imaging metrics did not differ between intervention groups and were not associated with symptoms. The current study found different diffusion-weighted MRI responses from the microscopic cellular structures of the corpus callosum between patients receiving a novel behavioral intervention and patients receiving enhanced usual care. Correlations with improvement of post-concussion symptoms were not evident.