Base Rates of Postconcussion Syndrome by Method of Symptom Report

The Significance of Pain Drawing as a Screening Tool for Cervicogenic Headache and Associated Symptoms in Chronic Fatigue

Purpose

Patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) present with a broad spectrum of symptoms, including headache. A simple, yet powerful tool – the pain drawing identifies essential aspects such as pain distribution. The aim with this study was to 1) evaluate the significance of pain drawing as a screening tool for cervicogenic headache using a predefined C2 pain pattern, 2) assess whether there was an association between dizziness/imbalance and a C2 pain pattern, and 3) compare subgroups according to the pain drawing with respect to pain characteristics and quality of life.

Patients and Methods

Pain drawings and clinical data from 275 patients investigated for ME/CFS were stratified into: 1) cervicogenic headache as determined by a C2 pain pattern, 2) headache with no C2 pain pattern, and 3) no headache. For inference logistic regression presented with odds ratios (OR) and 95% confidence intervals (95% CI) and Kruskal–Wallis test were applied.

Results

One hundred sixteen participants (42%) were stratified to the group for which the pain drawing corresponded to the C2 pain pattern, thus indicating putative cervicogenic origin of the headache. Dizziness/imbalance was strongly associated with a C2 pain pattern; OR 6.50 ([95% CI 2.42–17.40] p ˂ 0.00), whereas this association was non-significant for patients with headache and no C2 pain pattern. Those demonstrating a C2 pain pattern reported significantly higher pain intensity (p = 0.00) and greater pain extent (p = 0.00) than the other groups, and lower health-related quality of life (p = 0.00) than the group with no headache.

Conclusion

For patients with chronic fatigue who present with a C2 pain pattern (interpreted as cervicogenic headache) the pain drawing seems applicable as a screening tool for signs associated with neuropathic and more severe pain, dizziness and reduced quality of life as detection of these symptoms is essential for targeted treatment.

Comparing Traumatic Brain Injury Symptoms Reported via Questionnaires Versus a Novel Structured Interview

OBJECTIVE

Mild traumatic brain injury (mTBI) symptoms are typically assessed via questionnaires in research, yet questionnaires may be more prone to biases than direct clinical interviews. We compared mTBI symptoms reported on two widely used self-report inventories and the novel Structured Interview of TBI Symptoms (SITS). Second, we explored the association between acquiescence response bias and symptom reporting across modes of assessment.

METHOD

Level 1 trauma center patients with mTBI (N = 73) were recruited within 2 weeks of injury, assessed at 3 months post-TBI, and produced nonacquiescent profiles. Assessments collected included the SITS (comprising open-ended and closed-ended questions), Rivermead Post Concussion Symptoms Questionnaire (RPQ), Sport Concussion Assessment Tool-3 (SCAT-3) symptom checklist, and Minnesota Multiphasic Personality Inventory-2 Restructured Form True Response Inconsistency (TRIN-r) scale.

RESULTS

Current mTBI symptom burden and individual symptom endorsement were highly concordant between SITS closed-ended questions, the RPQ, and the SCAT-3. Within the SITS, participants reported significantly fewer mTBI symptoms to open-ended as compared to later closed-ended questions, and this difference was weakly correlated with TRIN-r. Symptom scales were weakly associated with TRIN-r.

CONCLUSIONS

mTBI symptom reporting varies primarily by whether questioning is open- vs. closed-ended but not by mode of assessment (interview, questionnaire). Acquiescence response bias appears to play a measurable but small role in mTBI symptom reporting overall and the degree to which participants report more symptoms to closed- than open-ended questioning. These findings have important implications for mTBI research and support the validity of widely used TBI symptom inventories.

Rating of pre-injury symptoms over time in patients with mild traumatic brain injury: the good-old-days bias revisited

OBJECTIVE

Post-concussion syndrome (PCS) occurs following mild traumatic brain injury (mTBI). Patients with mTBI are often assessed using self-report instruments that rely on perception of current symptoms compared to how they felt and functioned pre-injury. The objective was to examine reliability of patients' post-injury reporting of their pre-injury symptoms.

METHODS

We included two control groups (trauma patients without brain injury history and healthy controls) who were recruited at an outpatient surgical clinic and among the working and social environment of the researchers, respectively. The Head Injury Symptom Checklist (HISC) was used to assess pre-injury and current symptoms at four time points post injury. We included 836 patients with mTBIs, 191 trauma patients without brain injury history, and 100 healthy controls.

RESULTS

Patients with mTBI reported significantly more pre-injury symptoms than both control groups (p < .001). Forty-five percent of patients with mTBI were inconsistent in their pre-injury ratings across four assessments. Patients with post-injury PCS reported much greater pre-injury symptoms and were more often inconsistent.

CONCLUSION

Accurately assessing PCS by comparing pre with post-injury complaints is difficult, and may have implications for diagnosis when using self-report instruments. Therefore, post-injury PCS diagnosis should be interpreted with caution and PCS should ideally be examined using clinical examination.

Psychological Predictors of Postconcussive Symptoms Following Traumatic Injury

OBJECTIVE

To determine the contribution of demographics, injury type, pain, and psychological factors on postconcussive symptoms.

SETTING AND PARTICIPANTS

Recently injured (n = 54) and noninjured (n = 184) adults were recruited from a hospital emergency department or the community. Thirty-eight individuals met the diagnostic criteria for a mild traumatic brain injury and 16 individuals received treatment for a minor traumatic non-brain injury.

MAIN MEASURES

Standardized tests were administered to assess 4 postconcussion symptom types and theorized predictors including a "physiogenic" variable (injury type) and "psychogenic" variables (symptoms of anxiety, depression, and stress) within 1 month of the injury.

RESULTS

In the injured sample, after controlling for injury type, demographics, and pain (chronic and current), a hierarchical regression analysis revealed that the combination of psychological symptoms predicted affective (F10,42 = 2.80, P = .009, Rchange = 0.27) but not other postconcussion symptoms types. Anxiety (β = .48), stress (β = .18), and depression (β = -.07) were not statistically significant individual predictors (P > .05). Cognitive and vestibular postconcussion symptoms were not predicted by the modeled factors, somatic sensory postconcussion symptoms were predicted by demographic factors only, and the pattern of predictors for the symptom types differed for the samples.

CONCLUSIONS

Traditional explanatory models do not account for these findings. The predictors are multifactorial, different for injured versus noninjured samples, and symptom specific.

Acute post-concussive symptoms in young children

OBJECTIVES

Despite peaks of mild traumatic brain injury (mTBI) incidence in young children, few studies have examined the nature of post-concussive symptoms (PCSs) in children under the age of eight, whilst controlling for pre-injury symptoms and effects of trauma. The current study aimed to identify which PCSs differentiate children with mTBI from trauma controls early post-injury, and whether these differed among preschool and school-aged children.

METHODS

The sample comprised 101 children aged 2-12 presenting to an emergency department, with concussion or other minor bodily injury (control). Groups were divided by age (preschool and school-aged). PCSs were assessed within 72 hours post-injury using a comprehensive PCS checklist, administered to their parents via structured interview.

RESULTS

Parents of children with mTBI reported significantly more symptoms in their children than parents of children with other minor bodily trauma, p < 0.001, r = 0.84. Parents of preschool and school-aged children reported an equal number of symptoms. However, subtle differences were observed between symptom profiles of preschool and school-aged children.

CONCLUSIONS

Primary care clinicians should be aware of post-concussive symptom presentations in children of varying ages, in order to provide optimal care, especially in younger children. Methods of eliciting symptoms may influence the identification of symptoms. This issue warrants further examination in the paediatric population. ABBREVIATIONS ED emergency department; GCS Glasgow coma scale; mTBI mild traumatic brain injury; PCS post-concussive symptoms; PTA post-traumatic amnesia; TC trauma control.

Assessing Symptoms in Adolescents Following Sport-Related Concussion: A Comparison of Four Different Approaches

This study compared post-concussion symptom endorsements on the Post-Concussion Symptom Scale (PCSS) between a clinical open-ended interview, clinician-guided PCSS, parent-report PCSS, and computer-based PCSS in youth athletes with sport-related concussion (SRC). Participants included 54 patients aged 13-17 years (M = 15.19, SD = 1.29, 51.8% male) with a diagnosed SRC seen at a concussion clinic. Participants were administered a computer-based version (COMP) of the PCSS followed by clinical open-ended symptom interview (OPEN) and clinician-guided PCSS (GUIDED). Participants' parents concurrently and independently endorsed their children's symptoms by completing the PCSS in the waiting room (PARENT). Total number of symptoms reported and total symptom severity score were analyzed and compared across the four PCSS administration methods. Results revealed significantly lower total number of symptoms for OPEN compared to GUIDED (p = .002), PARENT (p < .001), and COMP (p = .006); and significantly lower total severity score for OPEN compared to GUIDED (p = .04) and PARENT (p < .001). These data support using the PCSS as a structured method of assessing post-concussion symptoms and question the utility of unstructured interview methods for assessing symptoms in youth athletes with SRC.

Assessment method influences the severity and type of symptoms reported after self-reported mild traumatic brain injury

OBJECTIVE

To investigate the influence of assessment method (spontaneous report versus checklist) on the report of postconcussive syndrome (PCS) symptoms after mild traumatic brain injury (mTBI).

SETTING

Community.

PARTICIPANTS

Thirty-six participants (58% female) with postacute self-reported mTBI (i.e., sustained 1-6 months prior to participation) and 36 age-, gender-, and ethnicity-matched controls with no history of mTBI.

DESIGN

Cross-sectional.

MAIN MEASURES

Spontaneous symptom report from open-ended questions and checklist endorsed symptoms from the Neurobehavioral Symptom Inventory (both measures administered online).

RESULTS

Assessment method significantly affected individual symptom item frequencies (small to large effects), the number of symptoms reported, the total severity score, domain severity scores (i.e., somatic/sensory, cognitive, and affective symptom domains), and the number of participants who met a PCS caseness criterion (large effects; checklist > spontaneous report). The types of symptoms that were different between the groups differed for the assessment methods: Compared to controls, the nonclinical mTBI group spontaneously reported significantly greater somatic/sensory and cognitive domain severity scores, whilst no domain severity scores differed between groups when endorsed on a checklist.

CONCLUSIONS

Assessment method can alter the number, severity, and types of symptoms reported by individuals who have sustained an mTBI and could potentially influence clinical decisions.

Depression, anxiety, and stress as predictors of postconcussion-like symptoms in a non-clinical sample

This study examined the relationship between postconcussion-like symptoms and depressive symptoms, anxiety and stress respectively. Seventy-one university students with a negative concussion history completed the Depression Anxiety Stress Scales (DASS) and the British Columbia Postconcussion Symptom Inventory (BC-PSI). A multiple regression was conducted using the three DASS subscale scores as predictors of postconcussion-like symptoms. Depressive symptoms, anxiety and stress were significantly positively correlated with postconcussion-like symptoms at the bivariate level. When these three factors were examined together 72.9% of variance in BC-PSI total scores was explained overall. Stress and depressive symptoms emerged as significant multivariate predictors explaining 15% and 3% of unique variance, respectively. Anxiety was not a significant multivariate predictor. These results suggest that stress may be a more important predictor of postconcussion-like symptoms than previously identified. Findings are interpreted in light of Iverson (2012) conceptual model of poor outcomes from mild traumatic brain injury.