A controlled historical cohort study on the post-concussion syndrome

Diet's Impact on Post-Traumatic Brain Injury Depression: Exploring Neurodegeneration, Chronic Blood-Brain Barrier Destruction, and Glutamate Neurotoxicity Mechanisms

Traumatic brain injury (TBI) has a profound impact on cognitive and mental functioning, leading to lifelong impairment and significantly diminishing the quality of life for affected individuals. A healthy blood-brain barrier (BBB) plays a crucial role in guarding the brain against elevated levels of blood glutamate, making its permeability a vital aspect of glutamate regulation within the brain. Studies have shown the efficacy of reducing excess glutamate in the brain as a treatment for post-TBI depression, anxiety, and aggression. The purpose of this article is to evaluate the involvement of dietary glutamate in the development of depression after TBI. We performed a literature search to examine the effects of diets abundant in glutamate, which are common in Asian populations, when compared to diets low in glutamate, which are prevalent in Europe and America. We specifically explored these effects in the context of chronic BBB damage after TBI, which may initiate neurodegeneration and subsequently have an impact on depression through the mechanism of chronic glutamate neurotoxicity. A glutamate-rich diet leads to increased blood glutamate levels when contrasted with a glutamate-poor diet. Within the context of chronic BBB disruption, elevated blood glutamate levels translate to heightened brain glutamate concentrations, thereby intensifying neurodegeneration due to glutamate neurotoxicity.

The Relation between Persistent Post-Traumatic Headache and PTSD: Similarities and Possible Differences

Post-traumatic headache (PTH) may be considered a secondary headache, which is linked to severe disability and psychosocial impairment. Interestingly, nearly 30% of subjects with persistent post-traumatic headache (PPTH) also suffer from post-traumatic stress disorder (PTSD). Although existing studies demonstrated the existence of common pathophysiological characteristics in subjects with migraine and PPTH, the differences and similarities between these complex diseases are currently poorly understood and are yet to be comprehensively elucidated. Thus, the present review aimed to systematically investigate the nature of PPTH in the effort to better identify both the neurobiological and clinical aspects underlying this condition. Overall, the included studies reported that: (1) the predictors for persistent acute traumatic injury to the head were female gender, persistent symptoms related to mild post-traumatic brain injury (mTBI), PTSD, elevated inflammatory markers, prior mild traumatic brain injury, being injured while suffering from alcohol abuse; (2) static/dynamic functional connectivity differences, white matter tract abnormalities, and morphology changes were found between PPTH and migraine in brain regions involved in pain processing; and (3) clinical differences which were most prominent at early time points when they were linked to the increased risk of PPTH. Based on the selected reports, the relation between migraine and PPTH needs to be considered bidirectionally, but PTSD may play a critical role in this relation. The main implications of these findings, with a specific focus on PTSD, are discussed. Further longitudinal studies are needed to reveal the exact nature of this relation, as well as to clarify the distinct clinical characteristics of migraine, PPTH, and PTSD.

Characterizing the Risk of Depression Following Mild Traumatic Brain Injury: A Meta-Analysis of the Literature Comparing Chronic mTBI to Non-mTBI Populations

Objective: Mild traumatic brain injury (mTBI) is associated with depressed mood acutely post-injury, but there is little evidence regarding long-term depression. The aim of this study was to determine the odds ratio (OR) of depression chronically following mTBI.

Methods: We searched Medline (PubMed), ProQuest, and Web of Science from date of database creation to January 23, 2019, for eligible studies examining depression at least 6 months post-injury in adult subjects with mTBI of any etiology, including civilians and military. Three authors independently reviewed titles and abstracts for study eligibility. Data were extracted and collated by two investigators. Risk of bias was assessed with the SIGN methodology. Study data were pooled using random-effects meta-analysis. The primary exposure was mTBI, and the primary outcome was depression. Secondary exploratory variables were time of assessment, age at injury, age at assessment, sex, and etiology.

Results: We included 47 cross-sectional studies (n = 25,103 mTBI and 29,982 control), 26 cohort studies (n = 70,119 mTBI, 262,034 control), four prospective observational studies (n = 1,058 mTBI and 733 control), two prospective longitudinal studies (n = 119 mTBI, 81 control), two case-control studies (n = 56 mTBI, 56 control), and one randomized controlled trial (n = 252 mTBI, 3,214 control). mTBI was associated with a 3.29-fold increased risk of depression (OR 3.29, 95% CI 2.68–4.03, I² = 96%). The OR for depression did not change when subjects were assessed at 6–12 months (OR 2.43, 1.45–4.07), years 1–2 (OR 4.12, 2.10–8.07); 2–10 (OR 3.28, 2.42–4.46), or 10+ (OR 3.42, 1.51–7.77). Similar risk of depression was sustained across different age at injury (<25: OR 2.26, 1.82–2.81; 25–35: OR 4.67, 3.06–7.14; >35: OR 2.69, 1.42–5.10) and different age at assessment (<40 years: OR 3.14, 2.48–3.99; >40 years: OR 4.57, 2.54–8.24). Female sex had a non-significant increase in OR (OR 19.97, 2.39–166.93) compared to male (OR 3.0, 2.33–3.86). mTBI etiology had no impact on depression.

Conclusions: Those experiencing mTBI are more than three times more likely to experience depression compared to those without a history of mTBI, and this risk remains decades beyond the mTBI event. Future longitudinal studies are needed to identify and mitigate this risk.

Impact of Pre-Existing Migraine and Other Co-Morbid or Co-Occurring Conditions on Presentation and Clinical Course Following Deployment-Related Concussion

OBJECTIVE

To describe the clinical presentation and early clinical course of a sample of deployed U.S. military service members following concussion, underscoring the impact of pre-existing migraine and other co-occurring conditions. It is important to obtain a comprehensive clinical history to identify evidence of underlying migraine and other health conditions which may contribute to an individual's presenting symptoms influencing early management and outcomes following concussion. Early outcome measures assessed include headache treatment response and fitness for return to duty.

BACKGROUND

Acute concussion is reported to result in an array of somatic, cognitive, and behavioral symptoms. It is well established that these symptoms are not specific for concussion and may result from exacerbation of pre-existing or underlying medical conditions and factors. Although most symptoms attributable to concussion resolve within days to weeks, there is evidence that persistent symptoms beyond that specific recovery time may be attributable to factors other than concussion. Military populations are at risk for a number of recognized co-morbid and co-occurring conditions, as well as special situational and psychosocial factors which may influence symptoms and clinical course following concussion. In addition, combat-related concussion frequently occurs in the setting of a blast or military vehicle accidents thus causing concurrent injuries where musculoskeletal injuries may contribute to the clinical presentation. The resultant acute stress reaction, secondary to the traumatic experience associated with concussion, may also cause or aggravate underlying psychological co-morbidities that may influence presenting symptoms. Prior studies identified co-morbidities associated with chronic post-concussive syndrome, which we find are also present during the early phase following deployment-related concussion, thereby influencing presentation and impacting recovery. This retrospective chart review was intended to demonstrate the presence and potential impact of co-morbid and co-occurring conditions contributing to symptoms following concussion, especially migraine due to its high prevalence among post-traumatic headaches.

METHODS

Retrospective chart review was performed by the treating neurologist of 40 service members following concussion in the deployed environment. Clinical symptoms and co-morbid and co-occurring conditions including evidence of pre-existing migraine identified during comprehensive neurologic evaluations were collected. Both pre-deployment/pre-traumatic and post-traumatic headache features supporting migraine and early instituted headache management and treatment response are described. Rates of return to duty in this sample were also tabulated.

RESULTS

Headaches were the most frequently reported acute symptom following concussion in this deployed service member population (38/40 patients [98%]), followed by insomnia, tinnitus, impaired concentration, nausea, dizziness, anxiety, impaired balance, depression, and hearing loss. Co-occurring acute injuries, acute stress reaction, and recent onset medication overuse were the most frequent co-occurring conditions identified by the treating neurologist as potentially contributing to the service member's presentation. Chronic co-morbidities identified included chronic headache, anxiety/depression, insomnia, and post-traumatic stress disorder. Service members with 3 or more identified co-morbidities or co-occurring conditions were more likely to require evacuation from theater. Pre-deployment headaches were reported by 25/40 [63%] service members, with 5/40 [12.5%] reporting known prior personal history of migraine. Of those reporting pre-deployment headaches, 21/25 [84%] described migraine features and/or triggers, though most [(15/25) 60%] reported as infrequent. Daily post-traumatic headaches were frequent (26/38 [68%]) and associated with typical migraine features and/or triggers. Of those treated with triptans (16/40 patient [42%]), most (12/16 patient [75%]) showed positive treatment response.

CONCLUSIONS

Concussion in the deployed settings does not occur in isolation, with co-morbid and co-occurring conditions being common. Presence of multiple co-morbidities appears to influence clinical course and overall recovery. Post-traumatic headaches are often phenotypically fully consistent with migraine, and appear related to pre-existing migraine if supported by detailed pre-deployment headache history suggesting same. Careful and comprehensive history taking and evaluation is invaluable in identifying associated conditions including migraine, potentially helping clinicians with more accurate symptom attribution, diagnoses, and improved clinical management following acute concussion.

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.

A Review of Tics Presenting Subsequent to Traumatic Brain Injury

Purpose of review

This review summarizes case reports of patients with tics emerging subsequent to traumatic brain injury (TBI), with respect to demographics, post-TBI symptoms, tic onset latency and topography, clinical history, neuroimaging results and treatment outcome.

Recent findings

Patients were 22 adults and 3 youth. Trauma onset appeared to fall mostly in adulthood. Two-thirds of patients were male and head trauma was related to motor vehicle accidents in most cases. Loss of consciousness was reported in just below half (48.0%) of cases. Associated physical and cognitive symptoms (e.g., impaired memory, reduced sensory perception, poor balance, muscle weakness, attention problems, aggression/impulsivity, obsessions and compulsions, depression and anxiety) were commonly reported. The latency between head trauma and tic onset varied, but generally ranged from one day post-trauma to approximately one year post-trauma. Sole presentation of motor tics was common, with rostral to caudal development of motor tics in other cases. Simple and/or complex vocal tics were present in several cases, often emerging after motor tics. Post-trauma obsessive-compulsive symptoms were noted in five cases (20.0%). A personal or family history of tics was reported in four cases. Damage to the basal ganglia, ventricular system, and temporal region was observed across ten patients (40.0%). Pharmacological intervention varied, with tic symptoms deemed to have significantly or somewhat improved in 12 cases (48.0%). A comparison of post-TBI symptoms in youth with head trauma history relative to those with peripheral injury suggests tic symptoms are not a common post-TBI symptom in youth.

Summary

Ultimately, there has been limited study on the link between traumatic brain injury and tic expression, and methodological issues preclude the ability to draw definitive conclusions regarding this relationship. Nevertheless, findings do suggest there may be heterogeneity in brain dysfunction associated with tic expression. Future case reports should utilize more systematic and thorough assessment of TBI and tics using validated measures, evaluate medication effects using single-case designs, and perform more longitudinal follow-up of cases with repeated neuroimaging.

Post traumatic headache (PTH) in a cohort of UK compensation claimants

AIM

To explore post traumatic headache characteristics and risk factors in compensation claimants by observational retrospective cohort analysis.

CASE RESULTS

Medicolegal reports on 116 consecutive compensation claimants aged 41.9 ± 15.0 years were reviewed 21 ± 14 months after injury. Eighty eight had suffered head and neck injuries, 21 reported only neck injury and seven had "other injuries". Ninety four percent of the head injuries were "mild". The incidence of post traumatic headache following neck injury did not differ from that following head and neck injury, and none of the "other injuries" cases developed post traumatic headache. We anticipated that all head and neck injury claimants would seek compensation for post traumatic headache, but 25% denied developing headache. Post traumatic headache was very strongly correlated with a past history of primary headache ( p < 0.0001) but no other risk factors were identified. Post traumatic headache semiology was consistent with "migraine" or "probable migraine" in 90% of cases. Headache resolved in 30% of claimants between 3 and 24 months after injury but 70% continued to suffer headaches at the time of assessment. Forty one percent of claimants had received no treatment for post traumatic headache in primary care.

CONCLUSIONS

Our data suggest that post traumatic headache is essentially "migraine" provoked by head or neck concussion. It is not clear why so many post traumatic headache sufferers receive poor or inadequate treatment for this condition.

Concussion

Concussion has been recognized as a clinical entity for more than 1000 years. Throughout the 20th century it was studied extensively in boxers, but it did not pique the interest of the general population because it is the accepted goal of the boxer to inflict such an injury on their opponent. In 2002, however, the possibility that repetitive concussions could result in chronic brain damage and a progressive neurologic disorder was raised by a postmortem evaluation of a retired player in the most popular sports institution in the United States, the National Football League. Since that time concussion has been a frequent topic of conversation in homes, schools, and on television and has become a major focus of sports programs in communities and schools at all levels. Now all 50 states, the District of Columbia, and the National Collegiate Athletic Association have enacted laws and rules to protect the athlete.

Associations Between Traumatic Brain Injury History and Future Headache Severity in Veterans: A Longitudinal Study

OBJECTIVE

To determine whether traumatic brain injury (TBI) history is associated with worse headache severity outcomes.

DESIGN

Prospective cohort study.

SETTING

Department of Veterans Affairs (VA) outpatient clinics.

PARTICIPANTS

Veterans (N=2566) who completed a mail follow-up survey an average of 3 years after a comprehensive TBI evaluation (CTBIE).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The presence or absence of TBI, and TBI severity were evaluated by a trained clinician and classified according to VA/Department of Defense clinical practice guidelines. Headache severity was evaluated at both the baseline CTBIE assessment and 3-year follow-up using a 5-level headache score ranging from 0 ("none") to 4 ("very severe") based on headache-associated activity interference in the past 30 days. We examined associations of mild and moderate/severe TBI history, as compared to no TBI history, with headache severity in cross-sectional and longitudinal analyses, with and without adjustment for potential confounders.

RESULTS

Mean headache severity scores were 2.4 at baseline and 2.3 at 3-year follow-up. Mild TBI was associated with greater headache severity in multivariate-adjusted cross-sectional analyses (β [SE]=.61 [.07], P<.001), as compared with no TBI, but not in longitudinal analyses (β [SE]=.09 [.07], P=.20). Moderate/severe TBI was significantly associated with greater headache severity in both cross-sectional (β [SE]=.66 [.09], P<.001) and longitudinal analyses (β [SE]=.18 [.09], P=.04).

CONCLUSIONS

Headache outcomes are poor in veterans who receive VA TBI evaluations, irrespective of past TBI exposure, but significantly worse in those with a history of moderate/severe TBI. No association was found between mild TBI and future headache severity in veterans. Veterans with headache presenting for TBI evaluations, and particularly those with moderate/severe TBI, may benefit from further evaluation and treatment of headache.

Headaches in patients with previous head injuries: A population-based historical cohort study (HUNT)

Background Headache attributed to head injury is claimed to be among the most common secondary headache disorders, yet available epidemiological evidence is scarce. We evaluated the prevalence of headache among individuals previously exposed to head injury by a comparison to an uninjured control group. Methods This population-based historical cohort study used data from hospital records on previous exposure to head injury linked to a large epidemiological survey with data on headache occurrence. Participants without head injury, according to hospital records, were used as controls. The head injuries were classified according to the Head Injury Severity Scale (HISS) and the International Classification of Headache Disorders (ICHD-3 beta). Binary logistic regression was performed to investigate the association between headache and head injury, controlling for potential confounders. Results The exposed group consisted of 940 individuals and the control group of 38,751 individuals. In the multivariate analyses, adjusting for age, sex, anxiety, depression and socioeconomic status, there were significant associations between mild head injury and any headache, migraine, chronic daily headache and medication overuse headache. Conclusion Headache was more likely among individuals previously referred to a hospital for a mild head injury compared to uninjured controls.

Prediction of headache severity (density and functional impact) after traumatic brain injury: A longitudinal multicenter study

BACKGROUND

Headache (HA) following traumatic brain injury (TBI) is common, but predictors and time course are not well established, particularly after moderate to severe TBI.

METHODS

A prospective, longitudinal cohort study of HA severity post-TBI was conducted on 450 participants at seven participating rehabilitation centers. Generalized linear mixed-effects models (GLMMs) were used to model repeated measures (months 3, 6, and 12 post-TBI) of two outcomes: HA density (a composite of frequency, duration, and intensity) and HA disruptions to activities of daily living (ADL).

RESULTS

Although HA density and ADL disruptions were nominally highest during the first three months post-TBI, neither showed significant changes over time. At all time points, history of pre-injury migraine was by far the strongest predictor of both HA density and ADL disruptions (odds ratio (OR) = 8.0 and OR = 7.2, averaged across time points, respectively). Furthermore, pre-injury non-migraine HA (at three and six months post-TBI), penetrating-type TBI (at six months post-TBI), and female sex (at six and 12 months post-TBI) were each associated with an increase in the odds of a more severe HA density. Severity of TBI (post-traumatic amnesia (PTA) duration) was not associated with either outcome.

CONCLUSION

Individuals with HA at three months after moderate-severe TBI do not improve over the ensuing nine months with respect to HA density or ADL disruptions. Those with pre-injury HA, particularly of migraine type, are at greatest risk for HA post-TBI. Other independent risk factors are penetrating-type TBI and, to a lesser degree and post-acutely only, female sex. Individuals with these risk factors should be monitored and considered for aggressive early intervention.

Posttraumatic headache

Headache is a common symptom after traumatic head injury and is a frequent feature of the postconcussive syndrome. A variety of headache subtypes can be precipitated by head trauma, although posttraumatic headaches most often resemble migraine or tension-type headache. A lack of clinical trials limits evidence-based treatment recommendations for both acute and chronic posttraumatic headaches. However, numerous pharmacologic and nonpharmacologic interventions can be used to successfully manage posttraumatic headaches. This article reviews the classification, epidemiology, prognosis, and pathophysiology of headaches after head trauma and provides a practical clinical approach for evaluating and treating patients with posttraumatic headaches.

Rasch analysis of the postconcussive symptom questionnaire: measuring the core construct of brain injury symptomatology

The Postconcussive Symptom Questionnaire (PCSQ; Lees-Haley, 1992 ) is purported to measure four constructs. These include psychological, cognitive, somatic, and infrequency (i.e., items intended to reflect negative impression management) symptoms. The utility and validity of Postconcussive Syndrome (PCS) as a diagnostic condition continues to be debated. To this end, examining the instruments used to measure postconcussive symptoms can increase our understanding with respect to this issue. The aim of this study was to derive a revised PCSQ to target the core construct of subjective symptoms reported by persons with traumatic brain injury (TBI). A total of 133 people with mild to severe TBI completed the 45-item PCSQ. Items were scored dichotomously, as symptom present or absent. Rasch analysis, based on the mathematical model formulated by Rasch ( 1960 ), was used to derive the revised PCSQ. Misfitting and redundant items were removed and a second model containing 19 items was fitted. The revised PCSQ-19 had superior psychometric qualities; reliability was 0.81. The PCSQ-19 provides a more targeted, unidimensional assessment of subjective symptoms following brain injury. The findings also revealed information related to symptom hierarchy which can further our understanding of PCS.

An examination of the base rates of post-concussion symptoms: the influence of demographics and depression

Post-concussion syndrome (PCS) is a controversial constellation of cognitive, emotional, and physical symptoms that some patients experience following a mild traumatic brain injury or concussion. PCS-like symptoms are commonly found in individuals with depression, pain, and stress, as well as healthy individuals. This study investigated the base rate of PCS symptoms in a healthy sample of 96 participants and examined the relationship between these symptoms, depression, and sample demographics. PCS symptoms were assessed using the British-Columbia Post-Concussion Symptom Inventory. Depression was measured using the Beck Depression Inventory II. Results demonstrated that: The base rate of PCS was very high; there was a strong positive relationship between depression and PCS; and demographic characteristics were not related to PCS in this sample. These findings are broadly consistent with literature suggesting a significant role for non-neurological factors in the expression of PCS symptomatology. This study adds to the growing body of literature that calls for caution in the clinical interpretation of results from PCS symptom inventories.

Rates of symptom reporting following traumatic brain injury

This study examines rates of reporting of new or worse post-traumatic symptoms for patients with a broad range of injury severity at 1 month and 1 year after traumatic brain injury (TBI), as compared with those whose injury spared the head, and assesses variables related to symptom reporting at 1 year post-injury. Seven hundred thirty two TBI subjects and 120 general trauma comparison (TC) subjects provided new or worse symptom information at 1 month and/or 1 year post-injury. Symptom reporting at 1 year post-injury was compared in subgroups based on basic demographics, preexisting conditions, and severity of brain injury. The TBI group reported significantly more symptoms at 1 month and 1 year after injury than TCs (each p < .001). Although symptom endorsement declined from 1 month to 1 year, 53% of people with TBI and 24% of TC continued to report 3 or more symptoms at 1 year post-injury. Symptom reporting in the TBI group was significantly related to age, gender, preinjury alcohol abuse, pre-injury psychiatric history, and severity of TBI. Symptom reporting is common following a traumatic injury and continues to be experienced by a substantial number of TBI subjects of all severity levels at 1 year post-injury.

Long-term neurologic outcomes after traumatic brain injury

OBJECTIVE

To determine the relations between traumatic brain injury (TBI) and several neurologic outcomes 6 months or more after TBI.

PARTICIPANTS

Not applicable.

DESIGN

Systematic review of the published, peer-reviewed literature.

PRIMARY MEASURES

Not applicable.

RESULTS

We identified 75 studies that examined the relations between TBI and neurologic outcomes. Unprovoked seizures are causally related to penetrating TBI as well as to moderate and severe TBI. There was only limited evidence of an association between seizures and mild TBI. Dementia of the Alzheimer's type (DAT) was associated with moderate and severe TBI, but not with mild TBI unless there was loss of consciousness (LOC); the evidence for the latter was limited. Parkinsonism was associated with moderate and severe TBI, but there was only modest evidence of a link with mild TBI without LOC. Dementia pugilistica was associated with professional boxing. There was insufficient evidence to support an association between TBI and both multiple sclerosis and amyotrophic lateral sclerosis. TBI appeared to produce a host of postconcussive symptoms (eg, memory problems, dizziness, and irritability). Moderate and severe TBI were associated with endocrine problems such as hypopituitarism and growth hormone deficiency and possibly with diabetes insipidus. There was only limited evidence of an association between mild TBI and the development of ocular/visual motor deterioration.

CONCLUSION

TBI is strongly associated with several neurologic disorders 6 months or more after injury. Clinicians caring for TBI patients should monitor them closely for the development of these disorders. While some of these disorders can be treated after they arise (eg, seizures), a greater public health benefit would be achieved by preventing them before they develop. Research efforts to develop therapies aimed at secondary prevention are currently underway.

Epidemiology of headache

Epidemiological studies conducted in the general population point to average headache prevalence rates of 46% for 1-year prevalence and of 64% for lifetime prevalence. For migraine, most studies conducted in the adult general population of western Europe and North America indicate rates between 5% and 9% in men, and between 12% and 25% in women. Non-western countries report lower figures. Migraine shows no gender differences in children, while in the elderly its frequency appears much reduced in both genders. About one-third of migraineurs suffer from migraine with aura. For tension-type headache, prevalence data reports in the literature are few and conflicting: rates range from 11% in Singapore to 20-40% in the USA and over 80% in Denmark. It is worth noting that the highest figures are found in studies where a personal interview has been employed. This probably indicates that the prevalence of this headache subtype is particularly sensitive to the method of data collection. Cluster headache occurs in 1-3 per thousand of the general population, with a gender (M:F) ratio of about 3:1. About 4% of the adult general population suffers from chronic daily headache.

Health status, not head injury, predicts concussion symptoms after minor injury

OBJECTIVE

Postconcussion (PC) syndrome etiology remains poorly understood. We sought to examine predictors of persistent PC symptoms after minor injury.

METHODS

Health status, symptom, and injury information were obtained on a sample of patients presenting to the emergency department after minor injury. Postconcussion and cognitive symptoms were assessed at 1, 3, and 12 months.

RESULTS

Among 507 patients enrolled, 339 had head injury. Repeated-measures logistic regression modeling of PC and cognitive symptom presence across time indicated that baseline mental health status and physical health status were most predictive of persistent symptoms. In contrast, head injury presence did not predict persistent PC syndrome.

DISCUSSION

Baseline mental health status and physical health status were associated with persistent PC syndrome after minor injury, but head injury status was not. Further studies of PC syndrome pathogenesis are needed.

Five-year outcome after mild head injury: a prospective controlled study

OBJECTIVES

To study the prevalence of post-concussion symptoms (PCS) 5-7 years after mild head injury (MHI) and to investigate whether patients suffer from more symptoms than the normal population.

METHODS

We conducted a 5- to 7-year follow-up of patients (n = 89) with MHI. Post-concussion symptoms were quantified with the Rivermead Post Concussion Symptoms Questionnaire (RPQ) and health-related quality of life (HRQL) was measured with the EuroQol-5D (EQ-5D). We also quantified subjective general health state with the EuroQol Visual Analogue Scale (EQ-VAS). An age- and sex-matched, but otherwise randomly chosen control group of 89 persons was recruited from the National Population Registry for a cross-sectional comparison. Twenty-eight patients (30%) and 27 (30%) controls responded.

RESULTS

Patients reported significantly (P = 0.017) more PCS (median RPQ score 10, 95% CI 2-20) than controls (median 2, 95% CI 0-4). They also reported significantly (P = 0.008) lower HRQL (median EQ-5D score 0.866, 95% CI 0.796-1.000) than controls (1.000, 95% CI 1.000-1.000), but there was no difference between the groups in their subjective ratings of general health state.

CONCLUSIONS

Patients reported significantly more PCS and lower HRQL 5 to 7 years after MHI than age- and sex-matched controls from the normal population.

Controversies in the evaluation and management of minor blunt head trauma in children

PURPOSE OF REVIEW

We present data from recently conducted research regarding controversial aspects of the evaluation and management of children with minor blunt head trauma.

RECENT FINDINGS

Clinicians frequently but at times indiscriminately perform computed tomography scans for children with minor blunt head trauma resulting in potentially harmful radiation exposure. Recent guidelines recognize the limited but increasing data available to make strong recommendations regarding appropriate neuroimaging decisions. Investigators have derived and validated clinical prediction models to accurately identify patients with substantial traumatic brain injury, though no clear definitive rule exists. Children younger than 2 years appear to have a higher risk of intracranial injury following minor head trauma. These patients can be difficult to assess, with the evidence suggesting the need for a more conservative approach to diagnostic imaging. We present current and accepted definitions of concussion along with risk factors and treatment for postconcussion syndrome. Current return-to-play guidelines suggest that athletes who have sustained concussion should not resume play until symptoms have resolved because of the possibility, though rare, of second impact syndrome.

SUMMARY

Research in the management of children with minor head trauma is actively evolving. We present a review of recent developments that can influence current clinical practice.

The Rivermead Post Concussion Symptoms Questionnaire: a confirmatory factor analysis

OBJECTIVE

To investigate the factor structure of the Rivermead Post Concussion Symptoms Questionnaire (RPQ) among individuals seen as part of routine follow-up following traumatic brain injury.

METHODS

RPQ data from 168 participants was examined (mean age 35.2, SD 14.3; 89% with post traumatic amnesia duration<24 hours) six months after admission to an Accident & Emergency Department following TBI. Structural equation modelling was carried out to evaluate proposed models of the underlying structure of post-concussion symptoms (PCS).

RESULTS

The results support the existence of separate cognitive, emotional and somatic factors, although there was a high degree of covariation between the three factors. A two-factor model that collapsed the emotional and somatic factors together showed a similar goodness-of-fit to the data, whilst a one-factor model proved a poor fit.

CONCLUSION

The results support the notion of post-concussion symptoms as a collection of associated but at least partially separable cognitive, emotional and somatic symptoms, although questions persist regarding symptom specificity. The use of the RPQ is discussed, and classification bands for use in clinical practice are suggested.

The validity of post-concussion syndrome in children: a controlled historical cohort study

The aim of this controlled historical cohort study was to assess the validity of post-concussion syndrome in children. We identified 301 children aged 4-15 years who had sustained an isolated brain concussion, and another group of 301 children who sustained any other mild body injury excluding the head. Parents from both groups filled in standardized questionnaires containing questions about the health condition of the children: headache, neck pain, dizziness, malaise, fatigability, exercise or noise intolerance, irritability, weepiness, sadness, anxiety, nocturnal enuresis, tics, sleep disorders, memory or learning difficulties, hyperactivity, seizures, attention disorder, buzzing in the ears, subjective parental concerns about the child's health condition, and parental concerns about their child having a brain disorder. The severity of the complaints was rated on the Visual Analogue Scale. After the final exclusion, 102 pairs strictly matched by sex, age, and the date of trauma were analyzed. The differences of parental complaints about the health condition of their children between case and control groups were statistically insignificant for all symptoms, except parental concerns about their child having brain damage which were significantly higher in the case group. The likelihood of parental concerns about the possibility of their child having brain damage was 2.7 times higher in the case group. Headache, learning difficulties, and sleep disorders were significant variables predicting the concerns. These results question the validity of the post-concussion syndrome in children.

Are mild head injuries as mild as we think? Neurobehavioral concomitants of chronic post-concussion syndrome

Background

Mild traumatic brain injury (MTBI) can sometimes lead to persistent postconcussion symptoms. One well accepted hypothesis claims that chronic PCS has a neural origin, and is related to neurobehavioral deficits. But the evidence is not conclusive. In the attempt to characterise chronic MTBI consequences, the present experiment used a group comparison design, which contrasted persons (a) with MTBI and PCS, (b) MTBI without PCS, and (c) matched controls. We predicted that participants who have experienced MTBI but show no signs of PCS would perform similar to controls. At the same time, a subgroup of MTBI participants would show PCS symptoms and only these volunteers would have poorer cognitive performance. Thereby, the performance deficits should be most noticeable in participants with highest PCS severity.

Method

38 patients with a single MTBI that had occurred at least 12 month prior to testing, and 38 matched controls, participated in the experiment. A combination of questionnaires and neuropsychological test batteries were used to assess the extent of PCS and related deficits in neurobehavioral performance.

Results

11 out of 38 MTBI participants (29%) were found to suffer from PCS. This subgroup of MTBI patients performed poorly on neuropsychological test batteries. Thereby, a correlation was found between PCS symptom severity and test performance suggesting that participants with more pronounced PCS symptoms performed worse in cognitive tasks. In contrast, MTBI patients with no PCS showed performed similar to matched control. We further found that loss of consciousness, a key criterion for PCS diagnosis, was not predictive of sustained PCS.

Conclusion

The results support the idea that MTBI can have sustained consequences, and that the subjectively experienced symptoms and difficulties in everyday situations are related to objectively measurable parameters in neurocognitive function.

Headache after moderate and severe traumatic brain injury: a longitudinal analysis

OBJECTIVES

To measure longitudinally headache (HA) after moderate and severe traumatic brain injury (TBI) and to examine potential association with demographic, injury, and psychologic factors.

DESIGN

Cohort study.

SETTING

Four Veterans Administration rehabilitation facilities (Minneapolis, Palo Alto, Richmond, Tampa) within the Defense and Veterans Brain Injury Center.

PARTICIPANTS

Consecutive patients (military or veteran beneficiaries) with moderate or severe TBI (N=109) who during acute rehabilitation consented to data collection and who completed 6- and 12-month follow-up evaluations.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

HA frequency, location, type, and incapacitation levels measured during prospective neurologic assessments.

RESULTS

Nearly 38% (41/109) of patients had acute posttraumatic headache (PTHA) symptoms; most often in a frontal location (20/41), most often of daily frequency (31/41), and showing no relation to injury severity, emotional, or demographic variables. Postacutely, PTHA symptom severity declined within the group. Better individual improvement was associated with less anxiety and depression at 6-month follow-up. Almost all subjects (21/22) with PTHA symptoms that persisted into the 6-month follow-up period reported symptoms again at 12-month follow-up.

CONCLUSIONS

PTHA severity in this sample of persons with moderate and severe TBI showed a pattern of improvement that leveled off by 6 months posthospitalization.

Definition, diagnosis, and forensic implications of postconcussional syndrome

Injuries from blows to the head often are manifested only as subjective complaints. Postconcussional syndrome thus can be feigned for financial or psychological gain. The authors review the pathology of brain trauma, symptoms of postconcussional syndrome, and criteria for diagnosis. In addition to somatic deficits, psychological and cognitive problems are common. The likelihood and severity of postconcussional syndrome are greater for women. Malingering may be suspected in cases involving litigation, and tests to detect it are available. Treatment for postconcussional syndrome depends on the specific symptoms. Pharmacotherapies may be helpful, but care should be used in prescribing drugs that could produce deleterious CNS effects.

Predictors of headache 22 years after hospitalization for head injury

OBJECTIVES

To assess predictors of headache in patients who had sustained a head injury 22 years earlier.

MATERIALS AND METHODS

A questionnaire about headache was sent to 361 subjects hospitalized for head injury in 1974-1975.

RESULTS

A total of 249 patients (69%) responded to the questionnaire. The prevalence of headache >14 days a month last year was 11%. In multivariate logistic regression analysis female sex (OR = 3.4, 95% CI 1.2-9.6), severe headache 3 months after the head injury (OR = 10.6, 95% CI 2.6-43.5) and psychiatric disease (OR = 2.9, 95% CI 1.1-7.7) predicted chronic headache. There was no significant association between chronic headache and post-traumatic amnesia or other trauma-related variables.

CONCLUSION

Female sex and headache 3 months after the head injury were the strongest predictors of long-term headache, while there was little association between long-term headache and trauma variables.

Outcome from mild traumatic brain injury

PURPOSE OF REVIEW

The focus of this review is outcome from mild traumatic brain injury. Recent literature relating to pathophysiology, neuropsychological outcome, and the persistent postconcussion syndrome will be integrated into the existing literature.

RECENT FINDINGS

The MTBI literature is enormous, complex, methodologically flawed, and controversial. There have been dozens of studies relating to pathophysiology, neuropsychological outcome, and the postconcussion syndrome during the past year. Two major reviews have been published. Some of the most interesting prospective research has been done with athletes.

SUMMARY

The cognitive and neurobehavioral sequelae are self-limiting and reasonably predictable. Mild traumatic brain injuries are characterized by immediate physiological changes conceptualized as a multilayered neurometabolic cascade in which affected cells typically recover, although under certain circumstances a small number might degenerate and die. The primary pathophysiologies include ionic shifts, abnormal energy metabolism, diminished cerebral blood flow, and impaired neurotransmission. During the first week after injury the brain undergoes a dynamic restorative process. Athletes typically return to pre-injury functioning (assessed using symptom ratings or brief neuropsychological measures) within 2-14 days. Trauma patients usually take longer to return to their pre-injury functioning. In these patients recovery can be incomplete and can be complicated by preexisting psychiatric or substance abuse problems, poor general health, concurrent orthopedic injuries, or comorbid problems (e.g. chronic pain, depression, substance abuse, life stress, unemployment, and protracted litigation).

A controlled prospective inception cohort study on the post-concussion syndrome outside the medicolegal context

In an earlier historical cohort study on the post-concussion syndrome (PCS) in Lithuania, a country in which there are few confounding factors, the validity of this condition as a disease entity could not be confirmed. In order to register the post-traumatic symptoms, the influence of sociodemographic factors, and the effect of expectation on these symptoms more reliably, we performed a controlled prospective study. Three hundred subjects with concussion were followed up with repeated questionnaires for 1 year. For each study subject, a sex- and age-matched control person with minor non-head injury was identified. These controls received similar questionnaires. Headache both after 3 months and after 1 year did not differ significantly between the head-injured participants and the non-head-injured controls. Several other symptoms attributed to PCS did not differ significantly between the groups after 3 months. After 1 year the vast majority of symptoms did not differ significantly. Exceptions were slightly significant differences concerning memory problems, concentration problems, dizziness and tiredness. These differences were insignificant when analysing symptoms in unmarried and/or people with lower education, separately. No relationship between cognitive dysfunction and the severity of concussion was found. Although the possibility of a mild organic brain injury cannot be completely ruled out, our results cast doubt on the validity of PCS as a useful clinical entity, at least for head injuries with loss of consciousness for <15 min. Sociodemographic factors and expectation seem to influence reporting of symptoms after concussion.

Occipital Nerve Blocks in Postconcussive Headaches

Headaches are common following traumatic brain injuries of all severities. Pain generators may be in the head itself or the neck. Headache assessment is discussed. Diagnosis and treatment of cervical headaches syndromes and, in particular, occipital neuralgia are reviewed. Finally, a retrospective study of 10 postconcussive patients with headaches who were treated with greater occipital nerve blocks is presented. Following the injection(s), 80% had a "good" response and 20% had a "partial" response. Occipital nerve block is a useful diagnostic and treatment modality in the setting of postconcussive headaches.

Psychological and Neuropsychological Integration in Multidisciplinary Pain Management After TBI

The intersection of traumatic brain injury and posttraumatic chronic pain poses a significant challenge for the health practitioner. Effective intervention requires psychological and neuropsychological evaluation, multidisciplinary teamwork, and an understanding of a wide range of pain disorders and their relationship to traumatic brain injury. Assessment must include documentation of both current functioning and premorbid history. Pain interacts with cognitive impairment, mood and anxiety disorders, dysinhibition syndromes, and personality disorders, posing significant diagnostic dilemmas and treatment challenges. Coordinated care requires multiple, ongoing interventions from a variety of specialists. Patient involvement, focusing on internal locus of control, mediates successful treatment.