Highlighting the differences in post-traumatic symptoms between patients with complicated and uncomplicated mild traumatic brain injury and injured controls

Identification of At-Risk Patients That Need More Intensive Treatment Following mTBI: Post-Hoc Insights From the UPFRONT-Study

OBJECTIVE

To investigate which factors within an at-risk group make patients less likely to benefit from preventive treatment following mild traumatic brain injury (mTBI).

SETTING

Inclusion in 3 level I trauma centers in the Netherlands. Data collection through surveys as outpatients.

PARTICIPANTS

mTBI patients (18-66 years), reporting 3 or more complaints 2 weeks postinjury (at-risk status). Eighty-four patients included and randomized (39 patients cognitive behavioral therapy, 45 patients telephonic counseling). Eighty patients filled out the questionnaires 12 months postinjury. Post hoc analysis investigating 80 patients as 1 at-risk group receiving psychological treatment.

DESIGN

Post hoc study of a randomized controlled trial (RCT). Binomial logistic regression performed determining which variables 2 weeks postinjury contributed strongly to unsuccessful return to work/study (RTW) and unfavorable outcome at 12 months.

MAIN MEASURES

RTW and functional outcome as measured with the Glasgow Outcome Scale-Extended (GOSE) at 12 months postinjury.

RESULTS

Out of 80 patients, 43 (53.8%) showed a favorable functional outcome at 12 months, and 56 (70%) patients had a full RTW. Patients with unfavorable outcome had a higher age and higher reports of anxiety, depression at 2 weeks and 12 months postinjury. Patients with an unsuccessful RTW had a higher age and higher reports of depression, and posttraumatic stress disorder at 2 weeks and 12 months postinjury. A logistic regression model for functional outcome (GOSE) was statistically significant (χ²7 = 40.30, P < .0001). Of 6 predictor variables, 3 were significant: anxiety, depression, and treatment condition. For RTW, logistic regression was also statistically significant (χ²7 = 19.15, P = .008), with only 1 out of 6 predictor variables (ie, age) being significant.

CONCLUSION

Main findings comprise differences in demographic and psychological measures between patients with favorable and unfavorable outcomes and patients with RTW versus no RTW. Prediction models of outcome and RTW showed several psychological measures at 2 weeks greatly determining patients' likelihood benefitting from the preventive treatment. Results suggest that from the beginning there are some patients for whom a short preventive treatment is not sufficient. Selection and treatment of at-risk patients might be better based on psychological symptoms instead of posttraumatic complaints.

Prevalence of insomnia and insomnia symptoms following mild-traumatic brain injury: A systematic review and meta-analysis

Sleep is commonly disrupted following mild traumatic brain injury (mTBI), however there is a lack of consensus in the existing literature regarding the prevalence of insomnia/insomnia symptoms after injury. The aim of this review was to conduct a systematic review and meta-analysis of insomnia and insomnia symptoms' prevalence following mTBI. Full-text articles published in English in peer-reviewed journals, including adults with a clinical or self-reported mild traumatic brain injury diagnosis, were eligible for inclusion. Studies that assessed insomnia/insomnia symptoms after injury were included. Of the 2091 records identified, 20 studies were included in the review. 19 of these were meta-analysed (n = 95,195), indicating high heterogeneity among studies. Subgroup analyses indicated pooled prevalence estimates of post-mTBI insomnia disorder of 27.0% (95% CI 6.49-54.68) and insomnia symptoms of 71.7% (95% CI 60.31-81.85). The prevalence of insomnia is significantly higher in individuals who have sustained mild traumatic brain injury compared to prevalence estimates reported in the general population but high heterogeneity and methodological differences among studies make it difficult to provide reliable prevalence estimates. Future research should continue to advance our understanding of the onset, progression and impact of post-mild traumatic brain injury insomnia to promote the recovery and wellbeing of affected individuals. PROSPERO registration CRD42020168563.

Personality Characteristics and Acute Symptom Response Predict Chronic Symptoms After Mild Traumatic Brain Injury

OBJECTIVE

Despite consensus that personality influences mild traumatic brain injury (mTBI) recovery, it has been underexamined. We evaluated the extent to which diverse personality and psychiatric symptom dimensions predict mTBI recovery.

METHODS

This prospective cohort study involved psychological assessments of hospital patients with mTBI (n = 75; median = 2 days post-injury, range = 0-12 days) and orthopedic trauma controls (OTC; n = 79) who were used for comparison in mediation modeling. Chronic symptoms were evaluated at 3 months after mTBI (n = 50) using the Sport Concussion Assessment Tool (SCAT) symptom checklist. Linear regression analyses were used to identify the predominant predictors of chronic symptoms in mTBI. Modern mediation analyses tested the hypothesis that personality traits predict chronic symptoms through acute psychological response to injury.

RESULTS

In mTBI, trait psychoticism directly predicted chronic mTBI symptoms and was the strongest personality predictor overall. Furthermore, an internalizing personality dimension emphasizing negative affect/emotionality and detachment predicted chronic mTBI symptoms indirectly through enhancement of acute somatic complaints. In OTC, internalizing personality acted through the same mediator as in mTBI, whereas the effect of psychoticism was also mediated through acute somatic complaints. There was varying support for a moderated direct effect of personality traits at low levels of positive emotionality across models.

CONCLUSION

These causal models provide novel insights about the role of personality in mTBI symptom recovery, highlighting the complexity of how psychological processes may interact to affect recovery and revealing that some of these processes may be non-specific to brain injury.

Mental health after paediatric concussion: a systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis sought to rigorously examine mental health outcomes following paediatric concussion. To date, heterogeneous findings and methodologies have limited clinicians' and researchers' ability to meaningfully synthesise existing literature. In this context, there is a need to clarify mental health outcomes in a homogeneous sample, controlling for key methodological differences and applying a consistent definition of concussion across studies.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

We searched Medline, Embase, PsycINFO, CINAHL, SportDiscus, Scopus and PubMed.

ELIGIBILITY

Peer-reviewed studies published between 1980 and June 2020 that prospectively examined mental health outcomes after paediatric concussion, defined as per the Berlin Consensus Statement on Concussion in Sport.

RESULTS

Sixty-nine articles characterising 60 unique samples met inclusion criteria, representing 89 114 children with concussion. Forty articles (33 studies) contributed to a random effects meta-analysis of internalising (withdrawal, anxiety, depression, post-traumatic stress), externalising (conduct problems, aggression, attention, hyperactivity) and total mental health difficulties across three time points post-injury (acute, persisting and chronic). Overall, children with concussion (n=6819) experienced significantly higher levels of internalising (g=0.41-0.46), externalising (g=0.25-0.46) and overall mental health difficulties compared with controls (g=0.18-0.49; n=56 271), with effects decreasing over time.

SUMMARY/CONCLUSIONS

Our review highlights that mental health is central to concussion recovery. Assessment, prevention and intervention of mental health status should be integrated into standard follow-up procedures. Further research is needed to clarify the mechanisms underlying observed relationships between mental health, post-concussion symptoms and other psychosocial factors. Results suggest that concussion may both precipitate and exacerbate mental health difficulties, thus impacting delayed recovery and psychosocial outcomes.

Development and description of SAAM intervention: A brief, multidimensional and psycho-educational intervention for adults with mild traumatic brain injury

BACKGROUND

Mild traumatic brain injury (mTBI) is associated with persistent post-concussive symptoms (PCSs) in approximately 15% of cases. These symptoms can be somatic (e.g., headache), cognitive (e.g., forgetfulness, poor attention and concentration capacities), emotional (e.g., anxiety, depression, irritability) and/or sleep-arousal complaints (e.g., fatigue, sleep problems). Although practice guidelines recommend early intervention to prevent and treat PCS, we still lack an effective, standardized, integrative, post-acute intervention based on a sound and validated theoretical model.

OBJECTIVES

The purpose of this article is to present the development and theoretical background underpinning a novel intervention for patients with PCSs in the post-acute phase after mTBI (1-3 months post-injury).

PROCEDURE

With a biopsychosocial approach (Hou et al., 2012) and best practice recommendations, we developed a novel multidimensional intervention targeting factors that perpetuate PCSs and that can be changed with the intervention. This individual-session intervention provides practical tools for managing PCSs and is designed to provide psycho-education and reassurance, reinforce individual objectives and promote a return to activities. Each session targets one category of PCSs: Sleep/fatigue, Attention, Anxiety/depressed mood, Memory/Organization (SAAM intervention). The rationale underlying the choices of format and content for the intervention is discussed, as are the associated strengths, limitations, opportunities and challenges.

CONCLUSION

This article could support researchers and clinicians to develop, replicate and/or implement interventions addressing current best practices in mTBI management.

Acute findings in an acquired neurosensory dysfunction

Background

In the Autumn of 2016, diplomatic personnel residing in Havana began to present with symptoms of dizziness, ear pain, and tinnitus that emerged after perception of high frequency noise and/or a pressure sensation. Understanding the acute symptoms of this disorder is important for better defining the disorder and developing optimal diagnostic, preventive, and treatment algorithms.

Objectives

To define the presenting symptoms in a cohort of patients in the acute time period after perceiving a noise/pressure exposure in Havana.

Design/Settings/Participants

Review of 25 symptomatic individuals who reported a localized sensation of noise/pressure and 10 asymptomatic individuals (roommates of those affected) who did not experience the sound/pressure.

Results

Immediately after the exposure, the majority of individuals reported intense ear pain in one or both ears and experienced tinnitus. All of the individuals noticed unsteadiness and features of cognitive impairment. On presentation to our center, dizziness (92%) and cognitive complaints (56%) were the most common symptoms. Formal testing revealed that 100% of individuals had an otolithic abnormality and evidence of cognitive dysfunction.

Conclusion and Relevance

This study focuses on the acute presentation of a phenomenon in which symptoms emerge after perception of a localized noise/pressure and in which the acute symptomology includes the universal nature of vestibular injuries and select cognitive deficits. The findings presented in this acute group of patients begin to provide a better picture of the initial injury pattern seen after this exposure and may allow for more accurate diagnosis of this disorder in future cases.

Level of Evidence

Retrospective review

Concussion

Concussions are a common injury for which patients often present first to primary care physicians. They can affect the day-to-day function of patients in school and work, as well as in sports and recreational activities. Recognizing common physical signs and symptoms after injury facilitates timely diagnosis and treatment, permitting initiation of an active management approach to recovery while preventing secondary injury. For persons with persistent symptoms, active rehabilitation may be utilized, with the goal of returning patients to full function.