Recovery from mild head injury

Mental Health Outcomes Across the Lifespan in Individuals With Persistent Post-Concussion Symptoms: A Scoping Review

Objective:

Concussion is a common yet heterogenous injury. Approximately 15–30% of cases present with persistent post-concussion symptoms (PPCS), continuing 4 weeks or more post-injury in children, youth, and adolescents, and 3 months or more in adults. There are known bidirectional links between PPCS and mental health outcomes. The focus of this scoping review is to explore the literature on mental health outcomes in individuals experiencing PPCS. Research objectives were to explore: (1) the mental health outcomes of individuals with PPCS and types of assessments used to identify mental health outcomes this group, and (2) how mental health outcomes compare in terms of similarities and differences among pediatric and adult populations with PPCS.

Method

Ovid MEDLINE; EMBASE; CINAHL, and PsycInfo databases were searched. After title and abstract screening of 11,920 studies, 481 articles were reviewed. Twenty-five papers met inclusion criteria. Results were organized by mental health outcomes of pediatric and adult populations, separately.

Results

There was a significantly higher number of studies devoted to adult populations. Of the 25 studies, 19 (76%) focused on adults, while six (24%) focused on adolescents. In adult populations, studies focused on symptoms of: anxiety (n = 2), depression (n = 8), and anxiety and depression (n = 9). Two studies assessed other emotional outcomes (10.5%). Within pediatric populations, an equal number of studies explored symptoms of: anxiety (n = 2), depression (n = 2), and anxiety and depression (n = 2). No studies focused on other emotional outcomes. Studies ranged greatly in methods, design, and control group. Most studies reported higher psychiatric symptoms of anxiety and/or depression in those with PPCS compared to individuals with recovered concussion or healthy controls.

Discussion

This review contributes to the understanding of mental health outcomes in those experiencing PPCS. Mental health and PPCS requires greater attention in pediatric populations, and consider strategies for those experiencing PPCS and mental health impacts. Future studies should consider including a wider range of emotional outcomes in their design, not limited to anxiety and depression. Study results may lead to improvements and research in the identification, assessment, and management of PPCS and mental health.

Use of the Sports Concussion Assessment Tool 3 in Emergency Department Patients With Psychiatric Disease

OBJECTIVE

The Sports Concussion Assessment Tool 3 (SCAT3) Symptom Evaluation (SE) is used in the emergency department (ED). This study aimed to examine the effects of psychiatric history on the SCAT3 SE symptom severity score (SSS).

SETTING

Three US EDs.

PARTICIPANTS

A total of 272 ED patients with suspected concussion.

DESIGN

Prospective, nonrandomized, nonblinded study. The SCAT3 SE SSS, demographic data, medical information, and self-reported psychiatric history were obtained from patients by clinical research staff when they presented to the ED seeking standard clinical care. Concussion diagnoses were determined following a comprehensive assessment by an ED physician trained in managing concussions and adjudicated by supervising physicians.

MAIN MEASURES

The primary outcome measure was SSS. The association between SSS, self-reported psychiatric disease, and concussion diagnosis was analyzed using multivariable linear regression.

RESULTS

68.4% of subjects were diagnosed with a concussion. After controlling for age, sex, race, history of previous concussion, and interval from injury to ED presentation, self-reported psychiatric history (adjusted regression coefficient (βa): 16.9; confidence interval [CI]: 10.1, 23.6), and concussion diagnosis (βa: 21.7; CI: 14.2, 29.2) were both independently associated with a significant increase in SSS. Subjects with a history of concussion had a significantly higher SSS (βa: 9.1; CI: 1.8, 16.5). Interval from injury to ED presentation was also associated with a significant increase in SSS (βa: 1.6 per 6-hour increase; CI: 0.4, 2.8).

CONCLUSION

Our findings demonstrate that a history of preexisting psychiatric disease, as self-reported by patients with a suspected concussion treated in the ED, is independently associated with significantly higher scores on the SCAT3 SE. This suggests that a history of psychiatric illness may need to be accounted for when the SCAT3 SE is used in the ED for the assessment of concussion.

Post-concussion symptoms three months after mild-to-moderate TBI: characteristics of sick-listed patients referred to specialized treatment and consequences of intracranial injury

Objective: To present pre-injury, injury-related, work-related and post-injury characteristics, and to compare patients with and without traumatic intracranial abnormalities, in a treatment-seeking sample with persistent post-concussion symptoms (PPCS) after mild-to-moderate TBI.Methods: Cross-sectional design in the context of a specialized TBI outpatient clinic. Eligible patients were aged 18-60 years, employed ≥ 50% at time of injury, and sick listed ≥ 50% at inclusion due to PPCS. Data were collected 8-12 weeks after injury through review of medical records, semi-structured interviews, questionnaires, and neuropsychological screening.Results: The study included 116 patients, of whom 60% were women, and predominantly white-collar workers in full-time positions. Ninety-four percent had a mild TBI, and 23% had intracranial abnormalities. The full sample reported high somatic, emotional, and cognitive symptom burden, and decreased health-related quality of life. Patients with normal CT/MRI results reported higher overall symptom burden, while patients with intracranial abnormalities had worse memory function.Conclusion: Injury severity and traumatic intracranial radiological findings should not be the sole ground for planning of rehabilitation service provision in patients with PPCS, as subjective complaints do not necessarily co-vary with these variables.

Epidemiologic Assessment of Concussions in an NCAA Division I Women's Soccer Team

Background:

Among collegiate sports, ice hockey and wrestling have been reported to have the highest rates of concussion injury. Recent literature has shown that among all sports, female soccer players had the highest rate of concussion injury at the high school level. Sport-specific analysis will increase our knowledge of epidemiologic characteristics of this serious injury in young soccer players, where “heading” is commonly involved during participation.

Hypothesis:

Heading during soccer will be associated with increased frequency of concussion injury in collegiate female players compared with other mechanisms of injury, and concussion injury mechanism and rates will differ by setting of injury (practice or match) and player position.

Study Design:

Descriptive epidemiologic study.

Methods:

This was a retrospective review and epidemiologic analysis of all concussions documented from a single National Collegiate Athletic Association (NCAA) Division I female collegiate soccer team between 2004 and 2017. A total of 381 participants were reviewed, and concussion injury mechanism, setting (practice or match), player position, and number of games and practices missed due to injury were analyzed.

Results:

Overall, 25 concussions in 22 players from the 2004 to 2017 seasons were identified, for an annual rate of 1.79 concussions per year. Collisions (36%) followed by headers (20%) were the most common mechanisms. Forwards sustained the most concussions (32%). Injuries were more common in games (56%) than practice (40%). Of note, the most common cause of concussion during practice was headers (40%). Of the concussions documented, 20 (91%) were the player’s first concussion. On average, each concussion resulted in a player missing 3.96 games and 12.46 practices.

Conclusion:

Our results demonstrate that concussion rates in female NCAA soccer players vary by position and occur with different frequencies and mechanisms in practice and games. Interventions for concussion avoidance should aim to limit exposure to high-risk activity, including player-to-player contact in games and headers in practice. Although gameplay and collisions can be unpredictable and difficult to control, practice settings can be modified in an attempt to decrease risk.

Mild traumatic brain injury in the United States: demographics, brain imaging procedures, health-care utilization and costs

Objective: To characterize mild traumatic brain injury (mTBI) patients in the USA, describing location of diagnosis, timing, and modality of imaging procedures, health-care resource utilization (HRU) and costs in the 12-month period post-diagnosis. Research Design: Retrospective claims analysis Methods: Anonymized data from the OptumHealth Care Solutions claims database (2006-2016). The index date was the first date with an mTBI diagnosis. HRU and costs (2016 USD) were assessed in the 12-month post-index period. Results: A total of 80,004 patients with mTBI were included: 60% were under 26 years and 54% were male. Mild TBI was most frequently diagnosed in an emergency department (ED) for all age groups, except patients aged 11-17 years, for whom the outpatient setting was the most frequent place of diagnosis. Almost half (47%) received brain imaging on the index date, with 98% of which receiving computed tomography. Mean follow-up health-care costs were $13,564 (SD = $41,071), primarily from inpatient ($4,675, SD = $29,982) and non-ED outpatient/physician office visits ($4,207, SD = $12,697). Older patients had greater HRU and higher health-care costs. Conclusions: The findings of this claims-based study show substantial HRU and costs associated with mTBI diagnosis during a 12-month follow-up period.

Concussion Alters the Functional Brain Processes of Visual Attention and Working Memory

Millions of North Americans sustain a concussion or a mild traumatic brain injury annually, and are at risk of cognitive, emotional, and physical sequelae. Although functional MRI (fMRI) studies have provided an initial framework for examining functional deficits induced by concussion, particularly working memory and attention, the temporal dynamics underlying these deficits are not well understood. We used magnetoencephalography (MEG), a modality with millisecond temporal resolution, in conjunction with a 1-back visual working memory (VWM) paradigm using scenes from everyday life to characterize spatiotemporal functional differences at specific VWM stages, in adults had had or had not had a recent concussion. MEG source-level differences between groups were determined by whole-brain analyses during encoding and recognition phases. Despite comparable behavioral performance, abnormal hypo- and hyperactivation patterns were found in brain areas involving frontoparietal, ventral occipitotemporal, temporal, and subcortical areas in concussed patients. These patterns and their timing varied as a function of VWM stagewise processing, linked to early attentional control, visuoperceptual scene processing, and VWM maintenance and retrieval processes. Parietal hypoactivation, starting at 60 ms during encoding, was correlated with symptom severity, possibly linked to impaired top-down attentional processing. Hyperactivation in the scene-selective occipitotemporal areas, the medial temporal complex, specifically the right hippocampus and orbitofrontal areas during encoding and/or recognition, lead us to posit inefficient but compensatory visuoperceptual, relational, and retrieval processing. Although injuries sustained after the concussion were considered "mild," these data suggest that they can have prolonged effects on early attentional and VWM processes.

Clinical evaluation of concussion: the evolving role of oculomotor assessments

Sports-related concussion is a change in brain function following a direct or an indirect force to the head, identified in awake individuals and accounting for a considerable proportion of mild traumatic brain injury. Although the neurological signs and symptoms of concussion can be subtle and transient, there can be persistent sequelae, such as impaired attention and balance, that make affected patients particularly vulnerable to further injury. Currently, there is no accepted definition or diagnostic criteria for concussion, and there is no single assessment that is accepted as capable of identifying all patients with concussion. In this paper, the authors review the available screening tools for concussion, with particular emphasis on the role of visual function testing. In particular, they discuss the oculomotor assessment tools that are being investigated in the setting of concussion screening.

Brain Volume, Connectivity, and Neuropsychological Performance in Mild Traumatic Brain Injury: The Impact of Post-Traumatic Stress Disorder Symptoms

Post-traumatic stress disorder (PTSD) is commonly associated with mild traumatic brain injury (mTBI). To better understand their relationship, we examined neuroanatomical structures and neuropsychological performance in a sample of individuals with mTBI, with and without PTSD symptoms. Thirty-nine subjects with mTBI were dichotomized into those with (n = 12) and without (n = 27) significant PTSD symptoms based on scores on the PTSD Checklist. Using a region-of-interest approach, fronto-temporal volumes, fiber bundles obtained by diffusion tensor imaging, and neuropsychological scores were compared between the two groups. After controlling for total intracranial volume and age, subjects with mTBI and PTSD symptoms exhibited volumetric differences in the entorhinal cortex, an area associated with memory networks, relative to mTBI-only patients (F = 4.28; p = 0.046). Additionally, subjects with PTSD symptoms showed reduced white matter integrity in the right cingulum bundle (axial diffusivity, F = 6.04; p = 0.020). Accompanying these structural alterations, mTBI and PTSD subjects also showed impaired performance in encoding (F = 5.98; p = 0.019) and retrieval (F = 7.32; p = 0.010) phases of list learning and in tests of processing speed (Wechsler Adult Intelligence Scale Processing Speed Index, F = 12.23; p = 0.001; Trail Making Test A, F = 5.56; p = 0.024). Increased volume and white matter disruptions in these areas, commonly associated with memory functions, may be related to functional disturbances during cognitively demanding tasks. Differences in brain volume and white matter integrity between mTBI subjects and those with mTBI and co-morbid PTSD symptoms point to neuroanatomical differences that may underlie poorer recovery of mTBI subjects who experience PTSD symptoms. These findings support theoretical models of PTSD and its relationship to learning deficits.

Impact of Mild Head Injury on Neuropsychological Performance in Healthy Older Adults: Longitudinal Assessment in the AIBL Cohort

Traumatic brain injury (TBI) is suggested to be a significant risk factor for dementia. However, little research has been conducted into long-term neuropsychological outcomes after head trauma. Participants from the Australian Imaging, Biomarkers and Lifestyle Study of Ageing (AIBL) who had recovered after sustaining a mild TBI involving loss of consciousness more than 5 years previously were compared with matched controls across a 3-year period. Bayesian nested-domain modeling was used to estimate the effect of TBI on neuropsychological performance. There was no evidence for a chronic effect of mild TBI on any neuropsychological domain compared to controls. Within the TBI group, there was some evidence suggesting that the age that the head trauma occurred and the duration of unconsciousness were modulators of episodic memory. However, these findings were not robust. Taken together, these findings indicate that adults who have sustained a TBI resulting in loss of consciousness, but who recover to a healthy level of cognitive functioning, do not experience frank deficits in cognitive ability.

Injury of the Arcuate Fasciculus in the Dominant Hemisphere in Patients With Mild Traumatic Brain Injury: A Retrospective Cross-Sectional Study

Little is known about injury of the arcuate fasciculus (AF) in patients with mild traumatic brain injury (TBI). We investigated injury of the AF in the dominant hemisphere in patients with mild TBI, using diffusion tensor tractography (DTT). We recruited 25 patients with injury of the left AF among 64 right-handed consecutive patients with mild TBI and 20 normal control subjects. DTTs of the left AF were reconstructed, and fractional anisotropy (FA), apparent diffusion coefficient (ADC), and fiber number of the AF were measured. Among 64 consecutive patients, 25 (39%) patients showed injury of the left AF. The patient group showed lower FA value and fiber number with higher ADC value than the control group (P < 0.05). On K-WAB evaluation, aphasia quotient and language quotient were 95.9 ± 4.1 (range 85-100) and 95.0 ± 5.4 (range 80-100), respectively. However, 23 (92.0%) of 25 patients complained of language-related symptoms after TBI; paraphasia in 12 (48.0%) patients, deficits of comprehension in 4 (16.0%) patients, deficits of speech production in 1 (4.0%) patient, and >2 language symptoms in 6 (24.0%) patients. We found that a significant number (39%) of patients with mild TBI had injury of the AF in the dominant hemisphere and these patients had mild language deficit. These results suggest that DTT could provide useful information in detecting injury of the AF and evaluation of the AF using DTT would be necessary even in the case of a patient with mild TBI who complains of mild language deficit.

Pharmacotherapy for chronic cognitive impairment in traumatic brain injury

BACKGROUND

Traumatic brain injury (TBI) is a major cause of chronic disability. Worldwide, it is the leading cause of disability in the under 40s, resulting in severe disability in some 150 to 200 million people per annum. In addition to mood and behavioural problems, cognition-particularly memory, attention and executive function-are commonly impaired by TBI. Cognitive problems following TBI are one of the most important factors in determining people's subjective well-being and their quality of life. Drugs are widely used in an attempt to improve cognitive functions. Whilst cholinergic agents in TBI have been reviewed, there has not yet been a systematic review or meta-analysis of the effect on chronic cognitive problems of all centrally acting pharmacological agents.

OBJECTIVES

To assess the effects of centrally acting pharmacological agents for treatment of chronic cognitive impairment subsequent to traumatic brain injury in adults.

SEARCH METHODS

We searched ALOIS-the Cochrane Dementia and Cognitive Improvement Group's Specialised Register-on 16 November 2013, 23 February 2013, 20 January 2014, and 30 December 2014 using the terms: traumatic OR TBI OR "brain injury" OR "brain injuries" OR TBIs OR "axonal injury" OR "axonal injuries". ALOIS contains records of clinical trials identified from monthly searches of a number of major healthcare databases, numerous trial registries and grey literature sources. Supplementary searches were also performed in MEDLINE, EMBASE, PsycINFO, The Cochrane Library, CINAHL, LILACs, ClinicalTrials.gov, the World Health Organization (WHO) Portal (ICTRP) and Web of Science with conference proceedings.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) assessing the effectiveness of any one centrally acting pharmacological agent that affects one or more of the main neurotransmitter systems in people with chronic traumatic brain injury; and there had to be a minimum of 12 months between the injury and entry into the trial.

DATA COLLECTION AND ANALYSIS

Two review authors examined titles and abstracts of citations obtained from the search. Relevant articles were retrieved for further assessment. A bibliographic search of relevant papers was conducted. We extracted data using a standardised tool, which included data on the incidence of adverse effects. Where necessary we requested additional unpublished data from study authors. Risk of bias was assessed by a single author.

MAIN RESULTS

Only four studies met the criteria for inclusion, with a total of 274 participants. Four pharmacological agents were investigated: modafinil (51 participants); (-)-OSU6162, a monoamine stabiliser (12 participants of which six had a TBI); atomoxetine (60 participants); and rivastigmine (157 participants). A meta-analysis could not be performed due to the small number and heterogeneity of the studies.All studies examined cognitive performance, with the majority of the psychometric sub-tests showing no difference between treatment and placebo (n = 274, very low quality evidence). For (-)-OSU6162 modest superiority over placebo was demonstrated on three measures, but markedly inferior performance on another. Rivastigmine was better than placebo on one primary measure, and a single cognitive outcome in a secondary analysis of a subgroup with more severe memory impairment at baseline. The study of modafinil assessed clinical global improvement (n = 51, low quality evidence), and did not find any difference between treatment and placebo. Safety, as measured by adverse events, was reported by all studies (n = 274, very low quality evidence), with significantly more nausea reported by participants who received rivastigmine compared to placebo. There were no other differences in safety between treatment and placebo. No studies reported any deaths.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine whether pharmacological treatment is effective in chronic cognitive impairment in TBI. Whilst there is a positive finding for rivastigmine on one primary measure, all other primary measures were not better than placebo. The positive findings for (-)-OSU6162 are interpreted cautiously as the study was small (n = 6). For modafinil and atomoxetine no positive effects were found. All four drugs appear to be relatively well tolerated, although evidence is sparse.

Speech-language pathology and concussion management in intercollegiate athletics: the Miami University Concussion Management Program

PURPOSE

The Miami University Concussion Management Program was established in 1999 to assess, manage, and monitor athletes who sustain concussions and experience neurobehavioral and neurocognitive symptoms secondary to their injury. The purpose of this article is to describe the established procedures of one of the oldest university-based interdisciplinary concussion management programs that is coordinated by speech-language pathologists (SLP).

METHOD

The theoretical and clinical underpinnings of baseline and postconcussion neurocognitive assessment and management procedures are discussed. Additionally, 2 illustrative case studies are presented to demonstrate the evolution and implementation of the interdisciplinary concussion management protocol and to present different patterns of concussion symptoms and recovery. Paper and computer-based neurocognitive assessment protocols are discussed and integrated in the case studies.

RESULTS/CONCLUSIONS

Successful management of sport-related concussion requires an interdisciplinary team that understands the unique neurobehavioral and neurocognitive symptoms associated with sports concussions. SLPs can play a valuable role on the interdisciplinary team in the prompt and appropriate management of postconcussion symptoms so that athletes can successfully return to their athletic, academic, and social activities.

Screening for traumatic brain injury: findings and public health implications

OBJECTIVE

To provide an overview of a series of projects that used a structured self-report screening tool in diverse settings and samples to screen for lifetime history of traumatic brain injury (TBI).

SETTING

Diverse community settings.

PARTICIPANTS

Homeless persons (n = 111), individuals with HIV seeking vocational rehabilitation (n = 173), youth in the juvenile justice system (n = 271), public schoolchildren (n = 174), substance users (n = 845), intercollegiate athletes (n = 90), and other community-based samples (n = 396).

DESIGN

Cross-sectional.

MAIN MEASURE

Brain Injury Screening Questionnaire.

RESULTS

Screening using the Brain Injury Screening Questionnaire finds that 27% to 54% of those in high-risk populations report a history of TBI with chronic symptoms. Associations between TBI and social, academic, or other problems are evident in several studies. In non-high-risk community samples, 9% to 12% of individuals report TBI with chronic symptoms.

CONCLUSION

Systematic TBI screening can be implemented efficiently and inexpensively in a variety of settings. Lifetime TBI history data gathered using a structured self-report instrument can augment existing estimates of the prevalence of TBI, both as an acute event and as a chronic condition. Identification of individuals with TBI can facilitate primary prevention efforts, such as reducing risk for reinjury in high-risk groups, and provide access to appropriate interventions that can reduce the personal and societal costs of TBI (tertiary prevention).

Diffusion tensor imaging for outcome prediction in mild traumatic brain injury: a TRACK-TBI study

We evaluated 3T diffusion tensor imaging (DTI) for white matter injury in 76 adult mild traumatic brain injury (mTBI) patients at the semiacute stage (11.2±3.3 days), employing both whole-brain voxel-wise and region-of-interest (ROI) approaches. The subgroup of 32 patients with any traumatic intracranial lesion on either day-of-injury computed tomography (CT) or semiacute magnetic resonance imaging (MRI) demonstrated reduced fractional anisotropy (FA) in numerous white matter tracts, compared to 50 control subjects. In contrast, 44 CT/MRI-negative mTBI patients demonstrated no significant difference in any DTI parameter, compared to controls. To determine the clinical relevance of DTI, we evaluated correlations between 3- and 6-month outcome and imaging, demographic/socioeconomic, and clinical predictors. Statistically significant univariable predictors of 3-month Glasgow Outcome Scale-Extended (GOS-E) included MRI evidence for contusion (odds ratio [OR] 4.9 per unit decrease in GOS-E; p=0.01), ≥1 ROI with severely reduced FA (OR, 3.9; p=0.005), neuropsychiatric history (OR, 3.3; p=0.02), age (OR, 1.07/year; p=0.002), and years of education (OR, 0.79/year; p=0.01). Significant predictors of 6-month GOS-E included ≥1 ROI with severely reduced FA (OR, 2.7; p=0.048), neuropsychiatric history (OR, 3.7; p=0.01), and years of education (OR, 0.82/year; p=0.03). For the subset of 37 patients lacking neuropsychiatric and substance abuse history, MRI surpassed all other predictors for both 3- and 6-month outcome prediction. This is the first study to compare DTI in individual mTBI patients to conventional imaging, clinical, and demographic/socioeconomic characteristics for outcome prediction. DTI demonstrated utility in an inclusive group of patients with heterogeneous backgrounds, as well as in a subset of patients without neuropsychiatric or substance abuse history.

Diminished brain resilience syndrome: A modern day neurological pathology of increased susceptibility to mild brain trauma, concussion, and downstream neurodegeneration

The number of sports-related concussions has been steadily rising in recent years. Diminished brain resilience syndrome is a term coined by the lead author to describe a particular physiological state of nutrient functional deficiency and disrupted homeostatic mechanisms leading to increased susceptibility to previously considered innocuous concussion. We discuss how modern day environmental toxicant exposure, along with major changes in our food supply and lifestyle practices, profoundly reduce the bioavailability of neuro-critical nutrients such that the normal processes of homeostatic balance and resilience are no longer functional. Their diminished capacity triggers physiological and biochemical 'work around' processes that result in undesirable downstream consequences. Exposure to certain environmental chemicals, particularly glyphosate, the active ingredient in the herbicide, Roundup(®), may disrupt the body's innate switching mechanism, which normally turns off the immune response to brain injury once danger has been removed. Deficiencies in serotonin, due to disruption of the shikimate pathway, may lead to impaired melatonin supply, which reduces the resiliency of the brain through reduced antioxidant capacity and alterations in the cerebrospinal fluid, reducing critical protective buffering mechanisms in impact trauma. Depletion of certain rare minerals, overuse of sunscreen and/or overprotection from sun exposure, as well as overindulgence in heavily processed, nutrient deficient foods, further compromise the brain's resilience. Modifications to lifestyle practices, if widely implemented, could significantly reduce this trend of neurological damage.

Posttraumatic headaches in civilians, soldiers, and athletes

Posttraumatic headaches are one of the most common and controversial secondary headache types. After mild head injury, more than 50% of people develop a postconcussion syndrome which has been controversial for more than 150 years. Headache is estimated as present in 30% to 90% of patients after mild head injury. Most headaches are of the tension type, although migraines can increase in frequency or occur acutely or chronically de novo. A review is provided of headaches in civilians, soldiers after blast trauma, athletes, and post-craniotomy including pathogenesis. The treatments are the same as for the primary phenotypes.

Health-related quality of life among people with epilepsy with mild seizure-related head injuries

Seizure-related head injury (SRHI) is an under-recognized condition frequently experienced by people with epilepsy (PWE). The purpose of this study is to investigate the potential impact of SRHI on health-related quality of life (HRQOL) among PWE receiving care in a tertiary epilepsy center. Consecutive adult PWE receiving care at the Baylor Comprehensive Epilepsy Center (BCEC) were recruited for the study. After their informed consent was obtained, patients were administered the QOLIE-31 to measure HRQOL and the NDDI-E to screen for depression. Simple linear regression was used to identify clinical variables associated with HRQOL and that included SRHI obtained systematically at each clinic visit. Data were also compared between the SRHI and non-SRHI groups. Participants included 172 subjects. Recurrent mild SRHI occurred in 50 (29%) subjects. Factors with a negative effect on HRQOL included depression (slope=-19.99 [95% CI -25.16, -14.81]; p<.0001), recurrent SRHI (-17.02 [-22.35, -11.69]; p<.0001), past SRHI (-13.46 [-18.43, -8.48]; p<.0001), and seizure frequency (-0.17 [-0.26, -0.07]; p=0.001) on univariate analysis. With stepwise multiple regression, depression and recurrent SRHI significantly impacted HRQOL with slopes (95% CI; p-value) of (-17.53 [-22.34, -12.73]; p<.0001) and (-14.03 [-18.78, -9.28]; p<.0001), respectively. Patient-derived HRQOL is negatively associated with depression and recurrent SRHI, independently. There has been a justifiable increased awareness of the potential effects of head injuries among healthy individuals. Our data suggest that head injuries can certainly be detrimental among PWE, and greater efforts should be made to recognize and formulate prevention strategies for SRHI.

Evaluating the cognitive consequences of mild traumatic brain injury and concussion by using electrophysiology

OBJECT

Mild traumatic brain injury (MTBI), often referred to as concussion when it occurs in sports, produces persistent cognitive problems in at least 15% of patients. Unfortunately, conventional neuropsychological tests usually yield results within normal limits in this population. The main objective of this event-related potential (ERP) study was to understand brain functioning during the performance of a working memory (WM) task in patients who have sustained an MTBI, mostly due to motor vehicle accident or sports concussion. This study also aimed for a better understanding of the association between brain functioning as measured with ERP, behavioral performance on the WM task, postconcussion symptoms, type of injury (that is, sports concussion vs other types), and time since the injury.

METHODS

Forty-four patients with MTBI (7.6 ± 8.4 months postinjury) were tested on a visual WM task with simultaneous recording of ERP, and were compared with 40 control volunteers who were their equivalent for age and sex. Amplitude and latency of frontal (N200 and N350) and parietal (P200 and P300) ERP waves were measured and were compared between groups. Correlation analyses were also performed between ERP characteristics, clinical variables, and behavioral performance.

RESULTS

A significant group difference was found for behavioral performance on the WM task, in which the MTBI group had a lower percentage of correct answers than the control group (p < 0.05). The patients with MTBI also had smaller amplitudes of both frontal N350 and parietal P300 ERP components when compared with control volunteers (p < 0.05). No changes were found for latency of ERP components. Smaller ERP amplitudes were associated with slower reaction times and worse accuracy on the WM task among patients with MTBI (p < 0.05). Types of injury (that is, sports concussion vs other mechanisms) were not associated with different ERP characteristics.

CONCLUSIONS

Abnormal ERP results are observed in patients after MTBI or sports concussion, even for those in the nonacute stage after their injury. Current standard clinical evaluations most often fail to detect cerebral dysfunction after MTBI, even when patients or athletes report symptoms. Clinicians should be aware that patients with MTBI, including sports concussion, probably have underlying mild but persistent cerebral dysfunctions that require further investigation.

Integrating Interventions after Traumatic Brain Injury: A Synergistic Approach to Neurorehabilitation

Deficits in attention, processing speed and executive functioning are among the most commonly reported and functionally limiting cognitive impairments among individuals with TBI. Changes in mood can exacerbate cognitive deficits and reduce life quality. Contemporary hierarchical models of cognitive functioning suggest that attention/arousal processes underlie and support higher-order functions. Building on decades of clinical research, a synergistic, integrative approach to neurorehabilitation is described, which combines bottom-up and top-town cognitive interventions in addition to psychotherapeutic interventions for mood. This approach is intended to address directly impairments in both foundational (i.e., attention) and higher-order (i.e., executive functions) processes. Executive dysfunction is addressed in a top-down fashion through the application of a series of problem-solving and emotional regulation modules that teach and integrate strategies that can be generalised across situations with practice. Attention, arousal and information processing are necessary prerequisites of successful higher-order thinking, attention skills, and are addressed in a bottom-up fashion through intensive individualised attention and processing training tasks. Combining top-down and bottom-up approaches within a comprehensive day-treatment programme can effect a synergistic improvement of overall functioning.

Epidemiology of neurologically disabling disorders

Neurological disorders place a considerable burden upon individuals, their families, and society. Some like stroke are common, while others like amyotrophic lateral sclerosis are much rarer. Some conditions such as multiple sclerosis are reported to vary by latitude, while others such as traumatic brain injury can vary considerably by locality. Depending upon the nature of the lesion, and factors such as time since onset, the consequences to the individual may also vary considerably, not just among different disorders, but within a given disorder. Consequently the patterns of disease incidence, its prevalence, and its consequences are complex and may vary not just because of the condition itself, but also because, for example, case ascertainment may vary from study to study. The cumulative annual incidence of disabling neurological disorders is likely to exceed 1000 per 100000, or 1% of the population. The incidence is characterized by significant variation, which is mediated by genetic, geographical, demographic, and environmental factors. While useful comparisons can be made through standardization techniques, planning for local services should be based upon local epidemiology, whenever available.

Magnetic resonance imaging improves 3-month outcome prediction in mild traumatic brain injury

OBJECTIVE

To determine the clinical relevance, if any, of traumatic intracranial findings on early head computed tomography (CT) and brain magnetic resonance imaging (MRI) to 3-month outcome in mild traumatic brain injury (MTBI).

METHODS

One hundred thirty-five MTBI patients evaluated for acute head injury in emergency departments of 3 LEVEL I trauma centers were enrolled prospectively. In addition to admission head CT, early brain MRI was performed 12 ± 3.9 days after injury. Univariate and multivariate logistic regression were used to assess for demographic, clinical, socioeconomic, CT, and MRI features that were predictive of Extended Glasgow Outcome Scale (GOS-E) at 3 months postinjury.

RESULTS

Twenty-seven percent of MTBI patients with normal admission head CT had abnormal early brain MRI. CT evidence of subarachnoid hemorrhage was associated with a multivariate odds ratio of 3.5 (p = 0.01) for poorer 3-month outcome, after adjusting for demographic, clinical, and socioeconomic factors. One or more brain contusions on MRI, and ≥4 foci of hemorrhagic axonal injury on MRI, were each independently associated with poorer 3-month outcome, with multivariate odds ratios of 4.5 (p = 0.01) and 3.2 (p = 0.03), respectively, after adjusting for head CT findings and demographic, clinical, and socioeconomic factors.

INTERPRETATION

In this prospective multicenter observational study, the clinical relevance of abnormal findings on early brain imaging after MTBI is demonstrated. The addition of early CT and MRI markers to a prognostic model based on previously known demographic, clinical, and socioeconomic predictors resulted in a >2-fold increase in the explained variance in 3-month GOS-E.

The Assessment of Executive Functioning Following Mild Traumatic Brain Injury

The assessment of executive functioning 1 month following a mild traumatic brain injury (MTBI) is minimal, inconsistent and difficult to integrate. Four executive processes of checking, inhibition, sharing and integrating were examined using an empirically derived assessment protocol based on executive process delineation (Baddeley & Della Sala, 1998). This protocol was administered to individuals at 1 month post-MTBI (n= 22), and a group of orthopaedic controls (n= 15) matched for age, sex, years of education and occupational status. Contrary to expectations, only one significant difference between the two groups occurred on the dual-task Telephone Search while Counting (p< .006), which was considered a measure of the executive process of sharing. Methodological limitations such as a small and heterogeneous sample may have influenced the findings in this study. The results provide support for the utility of a theoretically driven approach to executive functioning to aid the integration of neuropsychological results, and highlight the need for carefully controlled research at 1 month following a MTBI to further delineate the recovery process.

The Factor Structure of the Hospital Anxiety and Depression Scale (HADS) in a Traumatic Brain Injury (TBI) Population

rimary Objectives:To examine the HADS structure in TBI, using Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA), and investigate the effects of TBI severity, Gender, and Age on factor scores.Methods and Procedures:HADS data from 186 TBI patients in a population study in Tasmania were subjected to EFA. HADS data from a second sample of 185 TBI participants in the same study underwent CFA. One-month follow-up data were used, allowing inclusion of severe TBI patients while still being early post-injury. Factor loadings were used to investigate the effects of demographic and clinical variables at 2 weeks post-injury.Results:While EFA suggested 2-factor (anxiety, depression) and 3-factor (anxiety, psychomotor, depression) structures provided adequate descriptions, CFA strongly supported the 3-factor model. Using this model, significant effects of TBI severity were noted on Psychomotor and Depression scores at 2 weeks post-injury. Males reported significantly fewer symptoms on all 3 factors, as did younger participants.Conclusions:CFA indicates that a 3-factor model provides the best fit for HADS data in TBI. One factor, Psychomotor, has been relatively neglected in the literature, and the current findings suggest its assessment and rehabilitation should receive more attention.

Traumatic Brain Injury Without Loss of Consciousness: A Case Study

Whilst many investigators concede that traumatic brain injury (TBI) without loss of consciousness (LOC) can occur, the number of times that this phenomena is reported in the literature is small. This case report presents an instance of TBI without LOC as supported by the observation of slowed processing speed, anosmia and a marked post-traumatic dysexecutive syndrome featuring moderately severe disinhibition. The case is discussed with a view to determining the mechanics of the blow necessary to both damage the cerebral substance yet maintain consciousness intact.

Prevalence and treatment of headaches in veterans with mild traumatic brain injury

OBJECTIVES

To report the prevalence and characteristics of headaches in veterans with mild traumatic brain injury (TBI) and to describe most common treatment strategies after neurological evaluation.

METHODS

We conducted a retrospective cohort study. The setting was a United States Veterans Healthcare Administration Polytrauma Network Site. The study participants consisted of 246 veterans with confirmed diagnosis of mild TBI. The main outcome measures were: Self-reported head pain occurring 30 days prior to initial mild TBI screening; headache severity measured by the Neurobehavioral Symptom Inventory; headache characteristics; and treatment prescribed by neurologists.

RESULTS

The majority (74%) of veterans with a confirmed diagnosis of mild TBI (N=246), due largely to blast exposure, reported headaches in the 30 days preceding the initial mild TBI evaluation. Thirty-three percent of these veterans (N=81) were referred to neurology for persistent headaches. Of the 56 veterans attending the neurology evaluation, 45% were diagnosed with migraine headaches and 20% with chronic daily headaches. The most commonly used abortive agents were triptans (68%) and the most common preventive medications were anticonvulsants (55%) and tricyclics (40%).

CONCLUSION

There was an increased prevalence of headaches in veterans with mild TBI. Most of the TBI veterans in our study group were exposed to blast injury and findings indicate that the nature of head trauma may be contributing to headaches. Findings highlight the need for developing effective headache prevention and treatment strategies for all persons with mild TBI and in particular for veterans with blast-related mild TBI.

Mild head injury and sympathetic arousal: investigating relationships with decision-making and neuropsychological performance in university students

SUMMARY

The purpose of this study was to examine the relationships between neuropsychological performance, physiological arousal and decision-making in university students who have or have not reported a history of mild head injury (MHI).

METHODS

Forty-four students, 18 (41%) reporting a history of MHI, performed a design fluency task and the Iowa Gambling Task (IGT) while electrodermal activity (EDA) was recorded.

RESULTS

General cognitive ability and overall choice outcomes did not differ between groups. However, self-reported MHI severity predicted decision-making performance such that the greater the neural indices of trauma, the more disadvantageous the choices made by participants. As expected, both groups exhibited similar base levels of autonomic arousal and physiological responses to reward and punishment outcomes; however, those reporting MHI produced significantly lower levels of EDA during the anticipatory stages of decision-making.

CONCLUSIONS

Overall, these findings encourage the acceptance of head injury as being on a continuum of brain injury severity, as MHI can emulate neurophysiological and neuropsychological features of more traumatic cases and may be impacting mechanisms which sustain adaptive social decision-making.

Post-traumatic headache: is it for real? Crossfire debates on headache: pro

Mild traumatic brain injury is very common in Western societies, affecting approximately 1.8 million individuals in the USA. Even though between 30% and 90% of patients develop post-traumatic headache, post-traumatic headache remains a very controversial disorder. Particularly when it comes to chronic post-traumatic headache following mild closed head injury and headache attributed to whiplash injury. Some experts are disputing its existence as a genuine disorder. Indistinct disease classification, unresolved pathophysiological mechanism, and the role of accident-related legal issues further fuel this controversy. The complex combination of pain and neuropsychological symptoms needs further research in understanding the underlying pathophysiological mechanisms associated with the acute headache following trauma but more so the mechanisms associated with the development of chronic pain in some patients. Investigators should refrain from oversimplifying these complex mechanisms as hysteric exaggeration of everyday complains and from implying greed as motivation for this potentially very disabling disease.

Epidemiology of postconcussion syndrome in pediatric mild traumatic brain injury

BACKGROUND

Much disagreement exists as to whether postconcussion syndrome (PCS) is attributable to brain injury or to other factors such as trauma alone, preexisting psychosocial problems, or medicolegal issues. We investigated the epidemiology and natural history of PCS symptoms in a large cohort of children with a mild traumatic brain injury (mTBI) and compared them with children with an extracranial injury (ECI).

METHODS

This investigation was a prospective, consecutive controlled-cohort study of 670 children who presented to a tertiary referral emergency department with mTBI and 197 children who presented with ECI. For all participants, data were collected by use of a telephone interview of a parent 7 to 10 days after injury. If a change from preinjury symptoms was reported by a parent, follow-up continued monthly until symptom resolution. Outcomes were measured by using the Post Concussion Symptom Inventory, Rivermead Postconcussion Symptom Questionnaire, Brief Symptom Inventory, and Family Assessment Device.

RESULTS

There was a significant difference between the mTBI and ECI groups in their survival curves for time to symptom resolution (log rank [Mantel-Cox] 11.15, P < .001). Three months after injury, 11% of the children in the mTBI group were symptomatic (13.7% of children older than 6 years) compared with 0.5% of the children in the ECI group. The prevalence of persistent symptoms at 1 year was 2.3% in the mTBI group and 0.01% in the ECI group. Family functioning and maternal adjustment did not differ between groups.

CONCLUSIONS

Among school-aged children with mTBI, 13.7% were symptomatic 3 months after injury. This finding could not be explained by trauma, family dysfunction, or maternal psychological adjustment. The results of this study provide clear support for the validity of the diagnosis of PCS in children.

Post-traumatic headache

Post-traumatic headache (PTH) is a very controversial disorder, particularly when it comes to chronic PTH following mild closed head injury and headache attributed to whiplash injury. Nevertheless, mild traumatic brain injury is very common in Western societies, affecting approximately 1.8 million individuals in the USA. Between 30 and 90% of patients develop PTH. Generally, this headache resolves within the first 3 weeks after the accident without any specific therapy or long-term complications but in a minority of patients chronic PTH develops and can be associated with serious neurological and neuropsychological deficits. Sufficient psychological or neurobiological markers for PTH do not exist, thus treatment can be very challenging and should always be multidisciplinary, even in the early stages of disease, to make every reasonable effort in preventing the development of chronic pain.

Cognitive functions in relation to MRI findings 30 years after traumatic brain injury

OBJECTIVE

The aim of the study was to relate cognitive effects of a remote traumatic brain injury (TBI) to MRI findings and severity of injury.

METHOD

Sixty-one patients were assessed on average 30 years after a TBI of variable severity. A comprehensive cognitive test battery was used to evaluate memory, executive functions and cognitive overall impairment. Multiple regression analyses were used to examine the relationships between cognitive variables and MRI volumetric findings (the volumes of the hippocampus and the lateral ventricles) and local contusions on MRI. Also, the effect of injury severity on cognitive outcome was evaluated.

RESULTS

Reductions in hippocampal volumes and lateral ventricular enlargement were significantly associated with impaired memory functions, memory complaints and executive functions. Of the MRI parameters used, the best predictor for cognitive outcome was the volume of the lateral ventricle. There was only a modest relationship between severity of injury and cognitive performance.

CONCLUSIONS

The results show that long-term memory impairments after TBI are associated with MRI volumetric measures. This suggests that the degree of diffuse injury leading to atrophic changes is prognostically more important than the initial severity of TBI.

Determining long-term symptoms following mild traumatic brain injury: Method of interview affects self-report

PRIMARY OBJECTIVE

To examine the role played by two interviewing methods used (spontaneous response and suggested response) in the evaluation of long-term subjective post-mild traumatic brain injury (mTBI) symptoms.

RESEARCH DESIGN

Cohort study.

METHOD AND PROCEDURES

One hundred and eight adult participants were contacted for a follow-up telephone interview 12-36 months after their mTBI. The participants had to firstly spontaneously indicate symptoms that were still present following their mTBI (spontaneous response). Secondly, a list of symptoms was read to the participants and they had to say whether or not they were afflicted by each symptom (suggested response). Paired t-tests were performed to compare the means obtained using the two methods. The percentage of symptoms reported with the two interviewing methods were used to analyse symptom types.

EXPERIMENTAL INTERVENTION

None.

MAIN OUTCOMES AND RESULTS

Results show that participants reported significantly more symptoms and a given symptom when a list was read to the participants. Furthermore, neither the number of symptoms nor the type of symptoms reported is identical for the two interviewing methods.

CONCLUSION

The interviewing method used influences the number and type of long-term post-mTBI symptoms reported by participants.

Baseline predictors of fatigue 1 year after mild head injury

OBJECTIVE

To compare reports of fatigue 12 months after minor trauma by participants with mild head injury (MHI) with those with other injury, and identify injury and baseline predictors of fatigue.

DESIGN

An inception cohort study of participants with MHI and other nonhead injuries recruited from and interviewed at the emergency department (ED), with a follow-up telephone interview at 12 months.

SETTING

Level II community hospital ED.

PARTICIPANTS

Participants (n=58) with MHI and loss of consciousness (LOC) of 30 minutes or less and/or posttraumatic amnesia (PTA) less than 24 hours, 173 with MHI but no PTA/LOC, and 128 with other mild nonhead injuries.

INCLUSION CRITERIA

age 18 years or older, within 24 hours of injury, Glasgow Coma Scale score of 13 or higher, and discharge from the ED.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Medical Outcomes Study 36-Item Short-Form Health Survey Vitality subscale.

RESULTS

Significant predictors of fatigue severity at 12 months were baseline fatigue, having seen a counselor for a mental health issue, medical disability, marital status, and in some stage of litigation. Injury type was not a significant predictor.

CONCLUSIONS

Fatigue severity 12 months after injury is associated with baseline characteristics and not MHI. Clinicians should be cautious about attributing persisting fatigue to MHI without comprehensive consideration of other possible etiologic factors.

Diagnosis and Management of Post-Traumatic Vertigo

OBJECTIVES/HYPOTHESIS

Patients with post-traumatic vertigo can be difficult to treat secondary to the chronicity of their symptoms. Patients can have peripheral, central, and combined vestibular deficits. Furthermore, no comprehensive guidelines exist for returning these patients to work. The objectives of the study were to discuss diagnosis, management techniques, and guidelines for returning these patients to work.

STUDY DESIGN

Retrospective analysis of a tertiary referral neurotology and balance clinic.

METHODS

Between July 1997 and July 2003, 2390 patients with chief complaints of vertigo and/or dizziness were analyzed. Of these, 16 patients met the requirements for inclusion in the study, including head trauma and/or concussion and residual vertigo. Their inpatient and outpatient charts, imaging studies, audiograms, vestibular tests, and physical therapy evaluations were reviewed. All patients had at least 6 months of follow-up.

RESULTS

There were 5 women and 11 men, with an average age of 42 years. Five patients had symptoms consistent with traumatic perilymphatic fistulas, and two patients had symptoms consistent with post-traumatic Meniere's syndrome. Surgical therapy was not beneficial in relieving dysequilibrium. Balance testing results did not predict return-to-work status. Eleven patients were not allowed to return to work in any capacity, two patients were allowed to return to work with limited duties, and three patients were allowed to return to work with no restrictions.

CONCLUSION

Post-traumatic vertigo can result in chronic symptoms. Balance testing did not predict the ability of patients to return to work. Surgical intervention might not control patient symptoms. Many patients were unable to return to work.

Do UK university football club players suffer neuropsychological impairment as a consequence of their football (soccer) play?

Male players from football and rugby clubs and sportsmen from a variety of noncontact sports clubs at a UK university were compared on biographical and neuropsychological test measures. A data analysis paradigm was developed and employed to control the inflation of Type 1 error rate due to multiple hypotheses testing. Rugby players sustained most head injuries in their chosen sport, but neuropsychological tests of attention, memory, and executive function provided no evidence of performance impairment attributable to the number of head injuries sustained or the football, rugby, or noncontact sport groups. Footballers' heading frequency was related to the number of football head injuries sustained, but no relationship was detected between footballers' heading frequency and their neuropsychological test performance. Following discussion of pertinent methodological limitations it is concluded that there was no evidence in this dataset of neuropsychological impairment consistent with either mild head injury incidence or football heading frequency. However, a need for further research examining the long-term neuropsychological consequences of such head injuries was identified.

Mild traumatic brain injury and its sequelae: characterisation of divided attention deficits

Deficits in divided attention occur after a mild traumatic brain injury (MTBI) but many extant tasks lack sensitivity for detecting subtle cognitive difficulties. We use the Test d'Attention Partagee Informatise (TAPI), a novel dual-task paradigm, to investigate the impact of MTBI on the ability to divide attention between two stimuli sources. Individuals with MTBI (n=37) were evaluated within the first week following head trauma and at three months post-injury. A healthy control (HC) group (n=79) was also assessed. The primary outcome was reaction time and there were three different conditions that included visual target detection and auditory digit span tasks. Analyses utilised repeated measures ANOVA and ANCOVA models that adjusted for relevant variables including post-concussive and affective symptoms. Results indicated that at both baseline and follow-up, the MTBI group had significantly slower reaction time than the HC group. Also, both the MTBI and HC groups had slower reaction times as participants progressed through each of the more challenging TAPI conditions. This study supports the usefulness of this novel instrument and allows clinicians and researchers to assess for subtle divided attention deficits that may persist in those with MTBI even three months post-injury.

Initial reliability and validity of the Ohio State University TBI Identification Method

OBJECTIVES

Evaluate the psychometric properties of indices of a lifetime history of traumatic brain injury (TBI).

PARTICIPANTS

Convenience samples recruited from 2 treatment programs for persons with substance use disorders: N = 119 (study 1) and N = 103 (study 2)

DESIGN

Test interrater reliability (study 1) and predictive validity (Study 2).

MEASURES

Summary indices of the number, severity, timing, and effects of lifetime TBIs calculated from data elicited via a structured interview.

RESULTS

Interrater reliability was high. Factor analysis showed indices could be characterized by severity weighted counts of the number of injuries, both lifetime and in childhood, number of symptoms persisting, worst injury, time since last TBI with loss of consciousness, and age at first TBI with loss of consciousness. Age at injury and symptoms persisting contributed independently to the prediction of common cognitive and behavioral consequences of TBI.

CONCLUSION

These results provide preliminary support for the reliability and validity of summary indices of lifetime history of TBI elicited via a structured interview.

Comparison of preseason, midseason, and postseason neurocognitive scores in uninjured collegiate football players

BACKGROUND

College football players sustain an average of 3 subconcussive blows to the head per game. Concussions correlate with decreases in standardized neurocognitive test scores. It is not known whether repetitive, subconcussive microtrauma associated with participation in a full season of collision sport affects neurocognitive test scores.

HYPOTHESIS

No difference exists between preseason, midseason, and postseason Standardized Assessment of Concussion (SAC) and Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) scores when collegiate football players sustain subconcussive microtrauma from forceful, repetitive contact activity.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Fifty-eight members of a Division III collegiate football team who had no known concussion during the season voluntarily completed the SAC and ImPACT instruments preseason, midseason, and postseason. A repeated measures analysis of variance was used to compare the scores at the 3 time intervals (P < .05).

RESULTS

No statistically significant decreases were found in overall SAC or ImPACT scores or in any of the domains or composites of the tests (P < .05) when preseason, midseason, and postseason scores were evaluated.

CONCLUSIONS

ImPACT and SAC neurocognitive test scores are not significantly altered by a season of repetitive contact in collegiate football athletes who have not sustained a concussion.

CLINICAL RELEVANCE

A diminution in SAC or ImPACT scores in concert with clinical symptoms and findings should be interpreted as evidence of a postconcussive event.

Delineating Communication Impairments Associated With Mild Traumatic Brain Injury

BACKGROUND

Mild traumatic brain injury (mTBI) without frank neurological disturbance has been linked to persistent physical, cognitive, and affective disturbances in some cases. The cognitive sequelae of this syndrome represent the most frequently studied symptoms, yet the legacy of such injuries on communicative functions remains largely undetermined.

METHODS

A detailed language profile of a 19-year-old woman, 1 year 10 months following mTBI is compared with a matched normative cohort of 10 participants with nonneurological impairment.

RESULTS

Deficits in attention, lexical access, complex lexical-semantic manipulation, response monitoring, and organization were revealed as a consequence of mTBI.

CONCLUSIONS

This profile provides support for hypotheses pertaining to neuronal fallout mechanisms within the frontal lobes as a consequence of mild neurological insult.

Neuropsychological Impairment as a Consequence of Football (Soccer) Play and Football Heading: Preliminary Analyses and Report on University Footballers

Previous research has claimed neuropsychological impairment occurs as a result of professional and amateur football play, and, specifically, football heading. However, much of this research exhibits substantial methodological problems. By investigating less committed amateur level footballers, the current study sought to gain some insight into the developmental history of any neuropsychological consequences of football play. University football, rugby and noncontact sports players were compared on a range of biographical and neuropsychological test variables. While playing their chosen sports, rugby players sustained many more head injuries than footballers and noncontact sportsmen, but footballers did not sustain significantly more head injuries than noncontact sportsmen. The number of head injuries sustained predicted Trails B and TAP Divided Attention latencies in a positive fashion. After controlling for the number of head injuries sustained, sport group effects were detected with TAP Divided Attention accuracy scores, with footballers exhibiting poorest performance. After controlling for the number of head injuries sustained, the total amount of heading done by footballers predicted the number of Wisconsin Card Sorting category shifts in a negative fashion. Nevertheless, over interpretation of all of these results should be resisted because of the exploratory nature of the analyses and the possibility that the sport groups may differ in ways other than just the nature of their sports activities.

Compensation and Malingering in Traumatic Brain Injury: A Dose-Response Relationship?

The purpose of this study was to determine if there is a dose-response relationship between potential monetary compensation and failure on psychological indicators of malingering in traumatic brain injury. 332 traumatic brain injury patients were divided into three groups based on incentive to perform poorly on neuropsychological testing: no incentive; limited incentive as provided by State law; high incentive as provided by Federal law. The rate of failure on five well-validated malingering indicators across these groups was examined. Cases handled under Federal workers compensation laws showed considerably higher rates of failure and diagnosable malingering than cases handled under State law. The findings indicate that monetary compensation associated with workers compensation claims is a major motive for exaggeration and malingering of problems attributed to work-related brain injuries. The clinician's index of suspicion regarding exaggeration and malingering of symptoms and deficits should be much higher in the context of Federal workers compensation claims, particularly in patients who have suffered only mild traumatic brain injury.

Mild traumatic brain injury and anxiety sequelae: a review of the literature

There is scattered but significant psychological and neuropsychological evidence to suggest that mild traumatic brain injury (mild TBI) plays a notable role in the emergence and expression of anxiety. Conversely, there is also empirical evidence to indicate that anxiety may exert a pronounced impact on the prognosis and course of recovery of an individual who has sustained a mild TBI. Although the relationship between mild TBI and anxiety remains unclear, the present body of research attempts to elucidate a number of aspects regarding this topic. Overall, the mild TBI research is rife with inconsistencies concerning prevalence rates, the magnitude and implications of this issue and, in the case of PTSD, even whether certain diagnoses can exist at all. This review obviates the need for greater consistencies across studies, especially between varying disciplines, and calls for a shift from studies overly focused on categorical classification to those concerned with dimensional conceptualization.