Meta-analytic methods and the importance of non-TBI factors related to outcome in mild traumatic brain injury: response to Bigler et al. (2013)

Emotional functioning in long COVID: Comparison to post-concussion syndrome using the Personality Assessment Inventory

Objective: Recent studies on Long COVID found that patients report prominent emotional distress and significant correlations between distress and cognitive performance have been identified, raising the question of how to manage or treat these issues. To understand psychological functioning in Long COVID further, this study examined personality responses on the Personality Assessment Inventory (PAI) to compare psychological functioning in a Long COVID group with a post-concussion syndrome (PCS) group, a syndrome with a significant psychological component. Participants and methods: Participants included 201 consecutive Long COVID outpatients (Mean age = 48.87 years, mean education = 14.82, 71.6% Female, 82.6% White) and a comparison group of 102 consecutively referred PCS outpatients (Mean age = 46.08, mean education = 14.17, 63.7% Female, 88.2% White). Effect sizes and t-tests were calculated using the PAI validity, clinical, interpersonal, and treatment consideration scales as well as clinical subscales. Results: The results replicated earlier findings on the PAI in Long COVID by demonstrating that both Long COVID and PCS groups had the highest mean elevations on SOM and DEP scales but no statistically significant between group differences in mean scale elevations. Results support similarities in psychological functioning between Long COVID and PCS patients emphasizing the importance of evaluating psychological functioning in neuropsychological evaluations for these populations. Further, results suggest that psychological treatment strategies for PCS patients may be helpful for Long COVID patients, but more research is needed.

Cognitive Outcome After Complicated Mild Traumatic Brain Injury: A Literature Review and Meta-Analysis

Cognitive outcome for mild traumatic brain injury (mTBI) with positive brain imaging (complicated mTBI) was compared with that for mTBI with normal imaging (uncomplicated mTBI) and with moderate to severe TBI, using meta-analysis. Twenty-three studies utilizing objective neurocognitive tests were included in the analysis. At less than 3 months post-injury, complicated mTBI was associated with poorer cognitive outcomes than uncomplicated mTBI, but deficits were not comparable to those with moderate-severe TBI. After 3 months post-injury, a similar pattern was detected. Beyond 3 months, deficits in complicated mTBI relative to those with uncomplicated mTBI were present in processing speed, memory, executive function, and language, although the latter may be the result of reduced semantic fluency. The effect size of deficits in these domains was more marked in moderate-severe TBI. The available data support the use of complicated mTBI as a distinct classification in the prediction of cognitive outcome. The extent of cognitive deficit in complicated mTBI was small and unlikely to cause significant disability. However, patients with complicated mTBI constitute a broad category encompassing individuals who may differ markedly in the nature and extent of intracranial imaging abnormality, and further studies are warranted. Limitations of the available studies include small, selected samples; variations in TBI severity classification; absence of validity ("effort") testing; differing imaging methodology; and lack of long-term follow-up.

Post-Concussion Symptoms and Disability in Adults with Mild Traumatic Brain Injury: A Systematic Review and Meta-Analysis

Studies investigating long-term symptoms and disability after mild traumatic brain injury (mTBI) have yielded mixed results. This systematic review and meta-analysis aimed to determine the prevalence of self-reported post-concussion symptoms (PCS) and disability following mTBI. We systematically searched MEDLINE, Embase, CINAHL, CENTRAL, and PsycInfo to identify inception cohort studies of adults with mTBI. Paired reviewers independently extracted data and assessed risk of bias with the Scottish Intercollegiate Guidelines Network criteria. We identified 43 eligible studies for the systematic review; 41 were rated as high risk of bias, primarily due to high attrition (> 20%). Twenty-one studies (49%) were included in the meta-analyses (five studies were narratively synthesized; 17 studies were duplicate reports). At 3-6 months post-injury, the estimated prevalence of PCS from random-effects meta-analyses was 31.3% (95% confidence interval [CI] = 25.4-38.4) using a lenient definition of PCS (2-4 mild severity PCS) and 18.3% (95% CI = 13.6-24.0) using a more stringent definition. The estimated prevalence of disability was 54.0% (95% CI = 49.4-58.6) and 29.6% (95% CI = 27.8-31.5) when defined as Glasgow Outcome Scale-Extended <8 and <7, respectively. The prevalence of symptoms similar to PCS was higher in adults with mTBI versus orthopedic injury (prevalence ratio = 1.57, 95% CI = 1.22-2.02). In a meta-regression, attrition rate was the only study-related factor significantly associated with higher estimated prevalence of PCS. Setting attrition to 0%, the estimated prevalence of PCS (lenient definition) was 16.1%. We conclude that nearly one in three adults who present to an emergency department or trauma center with mTBI report at least mild severity PCS 3-6 months later, but controlling for attrition bias, the true prevalence may be one in six. Studies with representative samples and high retention rates are needed.

Network analysis of mild traumatic brain injury, persistent neurobehavioral and psychiatric symptoms, and functional disability among recent-era United States veterans

Recent-era U.S. veterans are clinically complex, with a high prevalence of co-occurring mild traumatic brain injury (mTBI), psychiatric conditions, and behavioral dysfunction. The current study examined the direct and indirect associations between mTBI and persistent neurobehavioral, psychiatric, and functional disability symptoms among recent-era U.S. veterans and service members (n = 648). We evaluated the postconcussive syndrome (PCS) potential causal model with two network analysis modeling approaches. Separate analyses were conducted for military mTBI and lifetime mTBI. An exploratory factor analysis was conducted to limit topological overlap in the network analysis. The most influential symptoms (i.e., the unique variables most strongly associated with the rest of the network) in the military mTBI network were behavioral disengagement, expected influence (EI) = 1.10; cognitive difficulties, EI = 1.08; agitation/irritability, EI = 1.05; and PTSD-related reexperiencing and avoidance symptoms, EI = 0.98. After accounting for other symptoms, mTBI was only minimally informative, EI = 0.34. Additionally, military mTBI did not moderate the association between symptoms or the overall connectivity of the network. The results for lifetime mTBI were consistent with those for military mTBI. The present analyses identified a variety of behavioral, cognitive, and emotional symptoms that play an important role in understanding comorbidity and daily functioning among recent-era U.S. veterans. Associations between cumulative mTBI that occurred in civilian or military settings were indirect and relatively small in magnitude. The current results add to a growing literature raising doubts about the PCS model.

Memory for forgetting in adults with persistent symptoms following concussion

INTRODUCTION

Persistent memory complaints following concussion often do not coincide with evidence of objective memory impairment. To the extent this clinical presentation represents Functional Cognitive Disorder (FCD), we would expect preservation or even enhancement of memory for instances of forgetting, based on two lines of prior evidence. First, emotional arousal enhances autobiographical memory. People who experience memory lapses as worrisome may better remember them. Second, individuals with FCD can paradoxically provide detailed accounts of memory lapses compared to patients with neurodegenerative disease, who tend to provide vague examples. The current study aimed to better characterize the recall of forgetting events in people with subjective memory problems following concussion.

METHODS

The study sample consisted of adults with chronic post-concussion symptoms (N = 37, M = 42.7 years old; 70.27% women; M = 24.9 months post-injury) and normal-range performance on conventional neuropsychological tests. Participants completed a measure of memory complaint severity and the Autobiographical Interview (AI). The AI was used to quantify the richness of narrative recollections of recent instances when they forgot something and (control) personal events that did not involve forgetting. Linear regression modeling assessed the relationship between memory complaint severity and AI variables, including narrative details, valence, arousal, and rehearsal of memories.

RESULTS

There was no association between memory complaint severity and memory for forgetting vs. control events. We further found no association between memory complaint severity and AI performance overall (collapsing across forgetting and control events). Participants with greater memory complaints experienced past memory lapses as more negative than control memories, but did not consistently differ on other AI phenomenological variables.

CONCLUSION

Autobiographical recall of memory lapses appears preserved but not selectively heightened in people who report experiencing severe memory problems long after concussion. This inconsistency supports conceptualization of persistent memory complaints after concussion as FCD.

Cognitive performance in older adults at three months following mild traumatic brain injury

Introduction: In the context of limited research assessing outcomes following mild traumatic brain injury (mTBI) in older adults, this study evaluated cognitive outcomes through prospective memory, and expected that performance of an older mTBI group (≥65 years) would be lower compared to orthopedic and community controls. The study also explored whether cognitive resources (retrospective memory, executive function) moderated any association between presenting Glasgow Coma Scale (GCS) and prospective memory.Method: At three-months post-injury, a mTBI group (n = 39), an orthopedic control group (n = 63), and a community control group (n = 46) completed a neuropsychological assessment, including (i) prospective memory, using a standardized paper-and-pencil task (Cambridge Prospective Memory Test), an augmented reality task and a naturalistic task, and (ii) standardized measures of retrospective memory (Hopkins Verbal Learning Test) and executive function (Trail Making Test). Group performances were compared, and bootstrapped moderation analyses evaluated the role of cognitive resources in the relationship between GCS and prospective memory outcome.Results: The mTBI group, as compared to community controls, performed significantly lower on the augmented reality task (d = -0.64 to d = -0.79), and there was a small-moderate but non-significant effect (d = -0.45) on the naturalistic task. There were no differences between the mTBI group and orthopedic controls. Retrospective memory was a unique predictor of the augmented reality task (B = 1.83) and moderated the relationship between presenting GCS and the naturalistic task (B = -5.60). Executive function moderated the association between presenting GCS and augmented reality (B = -1.13) and naturalistic task (B = -1.57).Conclusions: At three-months post-mTBI, older adults are at risk of poor cognitive performance; and the relationship between GCS and prospective memory can be moderated by cognitive resources. Further follow-up is indicated to determine whether impairments resolve or persist over time.

Perceived Recovery and Self-Reported Functioning in Adolescents with Mild Traumatic Brain Injury: The Role of Sleep, Mood, and Physical Symptoms

Purpose: To determine the contributions of anxiety, depressive, and concussion symptoms and sleep quality to self-perceived recovery in adolescents with concussion.Method: Adolescents aged 12-20 (n = 298) completed anxiety, depression, concussion symptoms, and sleep measures at an initial concussion clinic visit and three-month follow-up. At follow-up, they reported self-perceived recovery as percent back to normal.Results: Injury-related factors alone did not predict self-perceived recovery (R²_Adj =.017, p =.074). More concurrent physical, mental health, and sleep symptoms explained 18.8% additional variance in poorer self-perceived recovery (R²_Adj Change =.188, p <.05). Physical symptoms (B_stand = -.292) and anxiety (B_stand = -.260) accounted for the most variance in self-perceived recovery.Conclusion: Post-concussive symptoms, in particular anxiety and self-reported physical symptoms, seem to characterize protracted recovery. Self-perceived recovery as an outcome measure may provide a more holistic understanding of adolescents' experiences after concussion.

The effects of socioeconomic status on baseline neurocognitive testing scores

Baseline neurocognitive testing has been recommended to provide a more accurate representation of the pre-concussion cognitive status of individual athletes. Socioeconomic status is not typically controlled for when obtaining baseline scores, which may lead to inaccurate findings if post-injury scores are compared to normative data. Understanding the role of socioeconomic status in baseline testing is important for the accurate analysis of test scores and proper evaluation of patients if individualized baseline data are not available. Our purpose was to investigate the effects of socioeconomic status, as determined by eligibility for free or reduced cost lunch on baseline neurocognitive test scores in secondary school athletes. 1,788 secondary school athletes (females = 778, males = 1,010, age = 14.96 ± 1.11 years, height = 171.25 ± 17.83 cm, mass = 66.82 ± 21.63 kg) completed the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) upon starting scholastic athletics. ImPACT components (symptom severity scores and composite scores of verbal memory, visual memory, visual motor speed, and reaction time) served as the dependent variables. School administration coded free or reduced cost lunch eligibility (N = 1255 not eligible, N = 563 eligible) for each participant (group), which served as the independent variable. Free or reduced cost lunch eligibility significantly altered the combined dependent variables (multivariate F_5,1780=14.41, p < .001, ɳ² = .04) when sex and age were controlled. Follow up ANOVAs showed that participants eligible for free or reduced cost lunch scored significantly worse on verbal memory (F_1,1784 = 24.81, p < .001, ɳ² = .01), visual memory (F_1,1784 = 24.90, p < .001, ɳ² = .01), and visual motor speed (F_1,1784 = 50.54, p < .001, ɳ² = .03). In addition, slower reaction times (F_1,1784 = 35.10, p < .001, ɳ² = .02) and higher symptom severity scores (F_1,1784 = 10.37, p < .01, ɳ² = .01) were observed in those eligible for free or reduced cost lunch. If normative data are used instead of individual baselines, potential modifiers such as socioeconomic status should be taken into account when analyzing concussion scores to provide accurate diagnoses.

Optimizing Outcome Assessment in Multicenter TBI Trials: Perspectives From TRACK-TBI and the TBI Endpoints Development Initiative

Traumatic brain injury (TBI) is a global public health problem that affects the long-term cognitive, physical, and psychological health of patients, while also having a major impact on family and caregivers. In stark contrast to the effective trials that have been conducted in other neurological diseases, nearly 30 studies of interventions employed during acute hospital care for TBI have failed to identify treatments that improve outcome. Many factors may confound the ability to detect true and meaningful treatment effects. One promising area for improving the precision of intervention studies is to optimize the validity of the outcome assessment battery by using well-designed tools and data collection strategies to reduce variability in the outcome data. The Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study, conducted at 18 sites across the United States, implemented a multidimensional outcome assessment battery with 22 measures aimed at characterizing TBI outcome up to 1 year postinjury. In parallel, through the TBI Endpoints Development (TED) Initiative, federal agencies and investigators have partnered to identify the most valid, reliable, and sensitive outcome assessments for TBI. Here, we present lessons learned from the TRACK-TBI and TED initiatives aimed at optimizing the validity of outcome assessment in TBI.

Auditory and Cognitive Behavioral Performance Deficits and Symptom Reporting in Postconcussion Syndrome Following Mild Traumatic Brain Injury

Purpose This study examined auditory deficits and symptom reporting in individuals with long-term postconcussion symptoms following a single mild traumatic brain injury (mTBI) compared to age- and gender-matched controls without a history of mTBI. Method Case history interviews, symptom questionnaires, and a battery of central auditory and neuropsychological tests were administered to 2 groups. The mTBI group was a civilian population recruited from a local concussion management program who were seeking rehabilitation for postconcussion-related problems in a postacute period between 3 and 18 months following injury. Symptom validity testing was included to assess the rate of possible insufficient test effort and its influence on scores for all outcome measures. Analyses of group differences in test scores were performed both with and without the participants who showed insufficient test effort. Rates of symptom reporting, correlations among symptoms and behavioral test outcomes, and the relationships between auditory and cognitive test performance were analyzed. Results The mTBI group reported a high rate of auditory symptoms and general postconcussion symptoms. Performance on neuropsychological tests of cognitive function showed some differences in raw scores between groups, but when effort was considered, there were no significant differences in the rate of abnormal performance between groups. In contrast, there were significant differences in both raw scores and the rate of abnormal performance between groups for some auditory tests when only considering participants with sufficient effort. Auditory symptoms were strongly correlated with other general postconcussion symptoms. Conclusions Significant auditory symptoms and evidence of long-term central auditory dysfunction were found in a subset of individuals who had chronic postconcussion symptoms after a single mTBI unrelated to blast trauma. The rate of abnormal performance on auditory behavioral tests exceeded the rate of abnormal performance on tests of cognitive function. Supplemental Material https://doi.org/10.23641/asha.8329955.

Comprehensive analysis of the predictors of neurobehavioral symptom reporting in veterans

OBJECTIVE

This study assessed the strength of military-related concussion-, psychological-, and behavioral-related measures to predict neurobehavioral symptom (NBS) reporting in order to help clarify the extent to which persistent NBS reflect lingering effects of concussion vs other psychological/behavioral factors among veterans.

METHODS

Baseline analysis included 351 consecutively enrolled veterans in the Translational Research Center for Traumatic Brain Injury and Stress Disorders longitudinal cohort study. One hundred eighty-six returned for a follow-up evaluation averaging 24 months post baseline. The Neurobehavioral Symptom Inventory (NSI) was used to measure NBS reporting. Predictor variables included diagnosis of military-related mild traumatic brain injury (M-mTBI), psychological measures, including posttraumatic stress disorder, mood, anxiety, and substance abuse disorders, and behavioral measures, including self-reported current pain and sleep impairment. Hierarchical and multivariable regression analyses examined the relationships between the predictor variables and NSI scores. The k-fold cross-validation assessed generalizability and validity of the regressions.

RESULTS

Baseline analysis revealed that psychological and behavioral conditions independently accounted for 42.5% of variance in the NSI total score compared to 1.5% for M-mTBI after controlling for psychological and behavioral conditions. Prospective analysis revealed that M-mTBI at baseline did not significantly predict NSI score at follow-up, while psychological and behavioral measures at baseline independently accounted for 24.5% of NSI variance. Posttraumatic stress disorder was the most consistent predictor. Cross-validation analyses supported generalizability of the results.

CONCLUSIONS

Psychological and behavioral-related measures are strong predictors of persistent NBS reporting in veterans, while M-mTBI is negligible. NBS more likely reflect influential comorbidities as opposed to brain injury, per se.

Association between head injury and concussion with retinal vessel caliber

The adverse long-term consequences following traumatic brain injury are poorly understood, particularly on the cerebral microvasculature. Retinal vessels are a surrogate marker of cerebral vascular changes. We therefore aimed to examine the cross-sectional association between serious head injury or being knocked unconscious, and/or concussion and retinal microvascular signs, specifically, mean retinal arteriolar and venular calibre, in older adults after accounting for potential confounders. This cohort study involved 2,624 adults with mean age of 66.9 (±9.1) years who self-reported head injury and concussion parameters, and had gradable retinal photographs. Face-to-face interviews with trained interviewers allowed participants to report prior serious head injury or being knocked unconscious, and/or a previous diagnosis of concussion by a medical professional. Fundus photographs were taken and retinal vascular calibre measured using computer-assisted techniques and summarized. There were 25.9%, 15.3% and 10.1% who reported a prior serious head injury or being “knocked unconscious”, concussion, and both, respectively. Participants in the first group compared to non-injured participants had significantly wider (~2 μm) mean retinal venular calibre (p = 0.02), after adjusting for age, sex, smoking, body mass index, mean arterial blood pressure, type 2 diabetes and fellow vessel calibre. No significant associations were observed in people reporting medically diagnosed concussion or with mean retinal arteriolar calibre. Our exploratory study suggests that head injury is independently associated with wider retinal venular caliber. These findings warrant further investigation in longitudinal cohort studies.

Socioeconomic Status and Race Outperform Concussion History and Sport Participation in Predicting Collegiate Athlete Baseline Neurocognitive Scores

OBJECTIVES

The purpose of this study was to assess the contribution of socioeconomic status (SES) and other multivariate predictors to baseline neurocognitive functioning in collegiate athletes.

METHODS

Data were obtained from the Concussion Assessment, Research and Education (CARE) Consortium. Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) baseline assessments for 403 University of Florida student-athletes (202 males; age range: 18-23) from the 2014-2015 and 2015-2016 seasons were analyzed. ImPACT composite scores were consolidated into one memory and one speed composite score. Hierarchical linear regressions were used for analyses.

RESULTS

In the overall sample, history of learning disability (β=-0.164; p=.001) and attention deficit-hyperactivity disorder (β=-0.102; p=.038) significantly predicted worse memory and speed performance, respectively. Older age predicted better speed performance (β=.176; p<.001). Black/African American race predicted worse memory (β=-0.113; p=.026) and speed performance (β=-.242; p<.001). In football players, higher maternal SES predicted better memory performance (β=0.308; p=.007); older age predicted better speed performance (β=0.346; p=.001); while Black/African American race predicted worse speed performance (β=-0.397; p<.001).

CONCLUSIONS

Baseline memory and speed scores are significantly influenced by history of neurodevelopmental disorder, age, and race. In football players, specifically, maternal SES independently predicted baseline memory scores, but concussion history and years exposed to sport were not predictive. SES, race, and medical history beyond exposure to brain injury or subclinical brain trauma are important factors when interpreting variability in cognitive scores among collegiate athletes. Additionally, sport-specific differences in the proportional representation of various demographic variables (e.g., SES and race) may also be an important consideration within the broader biopsychosocial attributional model. (JINS, 2018, 24, 1-10).

Differences in Brain Architecture in Remote Mild Traumatic Brain Injury

Mild traumatic brain injury (mTBI) is brain trauma from an external impact with a loss of consciousness less than 30 min. Mild TBI results in several biopsychosocial impairments, with pronounced cognitive deficits thought to resolve within 3 months of injury. Previous research suggests that these impairments are due to a temporary inability to appropriately allocate neural resources in response to cognitive demands. Our study questioned this assumption and instead hypothesized that mTBI was associated with long-term neural disruptions and compromised brain structure integrity. By extension, we investigated the likelihood that functional restitution and cognitive resolution following mTBI may be due to some form of neurofunctional reorganization. To this end, we examined abnormalities in resting state functional connectivity and structure (volume, thickness, and fractional anisotropy) in two groups of mTBI-those with 1-10 years time post-injury (mTBI_1-10), and those with 20-65 years time post-injury, relative to age-, sex-, and education-matched controls. We observed abnormalities in brain architecture only in the mTBI_1-10 group, characterized by functional hypo-activation in the right frontal pole, smaller frontal pole volume, and lesser fractional anisotropy in the genu of the corpus callosum that extended near the right frontal pole. This frontal region is laterally specialized to regulate function specific to socio-emotional processes. Collectively, neural disruptions and structural insult in mTBI may persist up to 10 years following injury, but injury-related pathology may resolve with longer recovery time. Disruption to frontal-dependent function that supports socio-emotional processes also may interfere with cognitive functioning, as in the case of chronic mTBI.

Psychological interventions for persisting postconcussion symptoms following traumatic brain injury

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

To assess the benefits and harms of psychological interventions for people with persisting postconcussion symptoms.

Neuropsychiatric aspects of concussion: acute and chronic sequelae

Concussion – also known as mild traumatic brain injury – is a transient disturbance of neurological function resulting from traumatic forces imparted to the brain that often produce cognitive, behavioral and systemic symptoms. In this review of the literature, we discuss the pathophysiology of both acute and chronic neuropsychiatric sequelae of concussions, followed by a brief overview of evaluation and management of these sequelae.

Developing a Cognition Endpoint for Traumatic Brain Injury Clinical Trials

Cognitive impairment is a core clinical feature of traumatic brain injury (TBI). After TBI, cognition is a key determinant of post-injury productivity, outcome, and quality of life. As a final common pathway of diverse molecular and microstructural TBI mechanisms, cognition is an ideal endpoint in clinical trials involving many candidate drugs and nonpharmacological interventions. Cognition can be reliably measured with performance-based neuropsychological tests that have greater granularity than crude rating scales, such as the Glasgow Outcome Scale-Extended, which remain the standard for clinical trials. Remarkably, however, there is no well-defined, widely accepted, and validated cognition endpoint for TBI clinical trials. A single cognition endpoint that has excellent measurement precision across a wide functional range and is sensitive to the detection of small improvements (and declines) in cognitive functioning would enhance the power and precision of TBI clinical trials and accelerate drug development research. We outline methodologies for deriving a cognition composite score and a research program for validation. Finally, we discuss regulatory issues and the limitations of a cognition endpoint.

Balance function and sensory integration after mild traumatic brain injury

OBJECTIVE

This study examined the disparities in balance functions and sensory integration in patients with mild traumatic brain injuries (mTBIs) and healthy controls.

PARTICIPANTS

One hundred and seven patients with mTBI and 107 age- and sex-matched controls were recruaited for this study.

PRIMARY MEASURES

Symptoms of dizziness, balance functions and the ability to perform daily activities were assessed using the dizziness handicap inventory (DHI). This study also performed the postural-stability test and a modified clinical test of sensory integration by using the Biodex Stability System (BBS).

RESULTS

DHI scores (functional, emotional, physical and total self-reported scores) were substantially increased in patients following an mTBI compared with the scores of the controls (p < 0.000). The postural-stability test indices (anterior-posterior) (p = 0.045) and the sensory-integration test index (eyes-open-firm-surface index) (p = 0.006) were substantially lower in patients with mTBI than in the controls. However, indices of two other postural-stability test indices (overall and medial-lateral) and three other sensory-integration tests indices (eyes-closed-firm-surface, eyes-open-foam-surface and eyes-closed-foam-surface) measured for the mTBI group did not differ from those of the control group.

CONCLUSION

Activities of daily living, balance in postural stability and sensory integration were strongly impaired in patients with mTBI.

Psychological Characteristics in Acute Mild Traumatic Brain Injury: An MMPI-2 Study

The psychological characteristics of acute traumatic brain injury (TBI) have received limited research focus, despite empirical evidence of their relevance for subsequent psychological adjustment and early therapeutic intervention. This study addressed a wide range of psychological features in 47 individuals who were hospitalized as a result of acute mild TBI (mTBI). Participants were screened from amongst consecutive TBI admissions for moderate to severe brain injury, and for pre-injury neurological, psychiatric, or substance abuse histories. Clinical and content scale scores on the MMPI-2 were explored in relation to patient gender, age, level of education, and extent of cognitive complaints. The results revealed diverse psychosocial problem areas across the sample, the most common of which were somatic and cognitive complaints, compromised insight, and a naively optimistic self-perception. The mediating roles of injury severity and demographic variables are discussed. Clinical implications and specific recommendations are presented.

Participation in Pre-High School Football and Neurological, Neuroradiological, and Neuropsychological Findings in Later Life: A Study of 45 Retired National Football League Players

BACKGROUND

A recent study found that an earlier age of first exposure (AFE) to tackle football was associated with long-term neurocognitive impairment in retired National Football League (NFL) players.

PURPOSE

To assess the association between years of exposure to pre-high school football (PreYOE) and neuroradiological, neurological, and neuropsychological outcome measures in a different sample of retired NFL players.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Forty-five former NFL players were included in this study. All participants prospectively completed extensive history taking, a neurological examination, brain magnetic resonance imaging, and a comprehensive battery of neuropsychological tests. To measure the associations between PreYOE and these outcome measures, multiple regression models were utilized while controlling for several covariates.

RESULTS

After applying a Bonferroni correction for multiple comparisons, none of the neurological, neuroradiological, or neuropsychological outcome measures yielded a significant relationship with PreYOE. A second Bonferroni-corrected analysis of a subset of these athletes with self-reported learning disability yielded no significant relationships on paper-and-pencil neurocognitive tests but did result in a significant association between learning disability and computerized indices of visual motor speed and reaction time.

CONCLUSION

The current study failed to replicate the results of a prior study, which concluded that an earlier AFE to tackle football might result in long-term neurocognitive deficits. In 45 retired NFL athletes, there were no associations between PreYOE and neuroradiological, neurological, and neuropsychological outcome measures.

[Formula: see text] Effects of screening for postconcussive syndrome (PCS) on PCS symptom self-report and neuropsychological test performance

OBJECTIVE

Many non-neurological factors are related to postconcussive syndrome (PCS) symptom report and neuropsychological test performance in mild traumatic brain injury (mTBI). Use of mTBI screening instruments may also contribute to report of PCS symptoms and neuropsychological performance. We examined the impact of randomized PCS screening feedback on PCS symptom report and neuropsychological performance in 152 young adults with no history of mTBI.

METHOD

Participants were 158 undergraduates attending a medium-sized Midwestern university who completed the Postconcussive Syndrome Questionnaire (PCSQ) prior to the study and were randomly assigned to one of three conditions. Participants were either given feedback that they endorsed more symptoms than average, feedback that they endorsed fewer symptoms than average, or neutral information. Participants then completed the PCSQ for a second time as well as the Auditory Verbal Learning Test and Paced Auditory Serial Addition Test.

RESULTS

Contrary to expectations, participants receiving feedback that they endorsed more symptoms than average did not endorse more PCSQ symptoms post-feedback than participants in other conditions (p = .12); however, consistent with expectations, they demonstrated poorer verbal learning (p = .005) and delayed recall (p = .04) than participants in the below average feedback condition and reported higher rates of retrospective recall of prior mTBI than participants in the neutral condition (p = .01).

CONCLUSION

Results suggest that feedback from screening measures can influence individuals' performance and retrospective recall of their personal TBI history. Findings have implications for use of screening measures for PCS in clinical and research settings.

Mild traumatic brain injury in older adults: early cognitive outcome

Severe traumatic brain injury (TBI) in older age is associated with high rates of mortality. However, little is known about outcome following mild TBI (mTBI) in older age. We report on a prospective cohort study investigating 3 month outcome in older age patients admitted to hospital-based trauma services. First, 50 mTBI older age patients and 58 orthopedic controls were compared to 123 community control participants to evaluate predisposition and general trauma effects on cognition. Specific brain injury effects were subsequently evaluated by comparing the orthopedic control and mTBI groups. Both trauma groups had significantly lower performances than the community group on prospective memory (d=0.82 to 1.18), attention set-shifting (d=-0.61 to -0.69), and physical quality of life measures (d=0.67 to 0.84). However, there was only a small to moderate but non-significant difference in the orthopedic control and mTBI group performances on the most demanding task of prospective memory (d=0.37). These findings indicate that, at 3 months following mTBI, older adults are at risk of poor cognitive performance but this is substantially accounted for by predisposition to injury or general multi-system trauma.

A comparison of insufficient effort rates, neuropsychological functioning, and neuropsychiatric symptom reporting in military veterans and civilians with chronic traumatic brain injury

Neuropsychological evaluation of persons with chronic traumatic brain injury (TBI) symptoms is complicated by multiple factors. The authors explored the impact of mechanism of injury, effort testing performance, and neuropsychiatric status in a sample of military veterans (V-TBI) and civilians (C-TBI) with chronic TBI. V-TBI (n = 74), C-TBI (n = 67), and healthy civilian control (C-HC) participants (n = 66), completed a battery of neuropsychological, effort, and self-report neuropsychiatric measures. Results indicated that C-HC and C-TBI participants exhibited comparably low failure rates on effort tests (6% and 3%, respectively). V-TBI participants exhibited significantly higher rates of failure (18%). Subgroups (n = 20) of effort-screened participants matched for demographics and disability level were compared regarding neuropsychological performance and neuropsychiatric self-report. Both TBI groups exhibited limited neuropsychological impairment, relative to the C-HC participants. The V-TBI group exhibited pronounced neuropsychiatric symptomology compared with the other participant groups. The implications of these findings are discussed for evaluation in the context of disability and litigation.

Neuropsychological differential diagnosis of mild traumatic brain injury

The diagnosis and evaluation of mild traumatic brain injury (mTBI) is reviewed from the perspective of meta-analyses of neuropsychological outcome, showing full recovery from a single, uncomplicated mTBI by 90 days post-trauma. Persons with history of complicated mTBI characterized by day-of-injury computed tomography or magnetic resonance imaging abnormalities, and those who have suffered prior mTBIs may or may not show evidence of complete recovery similar to that experienced by persons suffering a single, uncomplicated mTBI. Persistent post-concussion syndrome (PCS) is considered as a somatoform presentation, influenced by the non-specificity of PCS symptoms which commonly occur in non-TBI samples and co-vary as a function of general life stress, and psychological factors including symptom expectation, depression and anxiety. A model is presented for forensic evaluation of the individual mTBI case, which involves open-ended interview, followed by structured interview, record review, and detailed neuropsychological testing. Differential diagnosis includes consideration of other neurologic and psychiatric disorders, symptom expectation, diagnosis threat, developmental disorders, and malingering.

Traumatic brain injury and chronic traumatic encephalopathy: a forensic neuropsychiatric perspective

Recent scientific reports and popular press describing chronic traumatic encephalopathy (CTE) collectively link this condition to a broad array of neuropsychiatric symptoms, including extremely rare and multi-determined behaviors such as murder-suicide. These reports are difficult to reconcile with several decades of research on the science of traumatic brain injury (TBI) and its consequences, especially the natural history and prognosis of mild TBI. This article attempts to reconcile these sources by reviewing the state of the science on CTE, with particular attention to case definitions and neuropathological criteria for this diagnosis. The evidence for links between TBI, CTE, and catastrophic clinical events is explored, and the complexity of attributing rare frequency behavioral events to CTE is highlighted. The clinical and medicolegal implications of the best available evidence are discussed, concluding with a cautionary note against prematurely generalizing current findings on CTE to entire populations of persons with, or at risk for, concussion exposures.

Effects and outcomes in civilian and military traumatic brain injury: similarities, differences, and forensic implications

Traumatic brain injury (TBI) is a prominent public health problem in both civilian and military settings. This article discusses similarities and differences in the assessment and treatment of TBI and the attendant forensic implications. Acute care and management of moderate/severe TBI tend to be similar across environments, as is the recognition of disability status in affected individuals. By contrast, an increased focus on mild TBI in recent years has resulted in a reliance on self-report and screening measures to validate the occurrence of events leading to injury. This has complicated assessment, treatment and subsequent medicolegal proceedings. The neuropsychological literature has provided significant guidance on these difficult issues, although the complexity of disability adjudication for active duty members of the military and veterans continues to pose challenges for clinicians in evaluative and treatment contexts.

Heterogeneity in Trail Making Test performance in OEF/OIF/OND veterans with mild traumatic brain injury

This study used cluster analysis to examine variability in Trail Making Test (TMT) performance in a sample of Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) veterans referred for mild traumatic brain injury (mTBI). Three clusters were extracted, two of which were characterized by level of performance and the third with a unique performance pattern characterized by slow performance on the TMT B (Low B). Clusters did not differ on demographic or psychiatric variables. The Above Average cluster had better performance on measures of processing speed, working memory, and phonemic fluency compared with the Low B cluster. Results suggest that a subset of patients with mTBI perform poorly on TMT B, which subsequently predicts poorer cognitive functioning on several other neuropsychological measures. This subset may be vulnerable to cognitive changes in the context of mTBI and multiple comorbidities while a number of other patients remain cognitively unaffected under the same circumstances.

Neuroimaging biomarkers in mild traumatic brain injury (mTBI)

Reviewed herein are contemporary neuroimaging methods that detect abnormalities associated with mild traumatic brain injury (mTBI). Despite advances in demonstrating underlying neuropathology in a subset of individuals who sustain mTBI, considerable disagreement persists in neuropsychology about mTBI outcome and metrics for evaluation. This review outlines a thesis for the select use of sensitive neuroimaging methods as potential biomarkers of brain injury recognizing that the majority of individuals who sustain an mTBI recover without neuroimaging signs or neuropsychological sequelae detected with methods currently applied. Magnetic resonance imaging (MRI) provides several measures that could serve as mTBI biomarkers including the detection of hemosiderin and white matter abnormalities, assessment of white matter integrity derived from diffusion tensor imaging (DTI), and quantitative measures that directly assess neuroanatomy. Improved prediction of neuropsychological outcomes in mTBI may be achieved with the use of targeted neuroimaging markers.