Systematic Review of Multivariable Prognostic Models for Mild Traumatic Brain Injury

Rehabilitation of Persistent Symptoms After Concussion

Persistent symptoms following a mild traumatic brain injury are challenging to treat and pose a significant threat to community reintegration. Early recognition and intervention play a pivotal role in preventing the development of persistent symptoms by providing education that emphasizes clear recovery expectations and the high likelihood of full symptom resolution. We recommend early development of a personalized treatment plan, offering guidance on gradual return to activity and specific symptom-targeted treatments that may incorporate both pharmacologic and nonpharmacologic interventions.

Prior traumatic brain injury is a risk factor for in-hospital mortality in moderate to severe traumatic brain injury: a TRACK-TBI cohort study

ABSTRACT

Objectives

An estimated 14-23% of patients with traumatic brain injury (TBI) incur multiple lifetime TBIs. The relationship between prior TBI and outcomes in patients with moderate to severe TBI (msTBI) is not well delineated. We examined the associations between prior TBI, in-hospital mortality, and outcomes up to 12 months after injury in a prospective US msTBI cohort.

Methods

Data from hospitalized subjects with Glasgow Coma Scale score of 3-12 were extracted from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury Study (enrollment period: 2014-2019). Prior TBI with amnesia or alteration of consciousness was assessed using the Ohio State University TBI Identification Method. Competing risk regressions adjusting for age, sex, psychiatric history, cranial injury and extracranial injury severity examined the associations between prior TBI and in-hospital mortality, with hospital discharged alive as the competing risk. Adjusted HRs (aHR (95% CI)) were reported. Multivariable logistic regressions assessed the associations between prior TBI, mortality, and unfavorable outcome (Glasgow Outcome Scale-Extended score 1-3 (vs. 4-8)) at 3, 6, and 12 months after injury.

Results

Of 405 acute msTBI subjects, 21.5% had prior TBI, which was associated with male sex (87.4% vs. 77.0%, p=0.037) and psychiatric history (34.5% vs. 20.7%, p=0.010). In-hospital mortality was 10.1% (prior TBI: 17.2%, no prior TBI: 8.2%, p=0.025). Competing risk regressions indicated that prior TBI was associated with likelihood of in-hospital mortality (aHR=2.06 (1.01-4.22)), but not with hospital discharged alive. Prior TBI was not associated with mortality or unfavorable outcomes at 3, 6, and 12 months.

Conclusions

After acute msTBI, prior TBI history is independently associated with in-hospital mortality but not with mortality or unfavorable outcomes within 12 months after injury. This selective association underscores the importance of collecting standardized prior TBI history data early after acute hospitalization to inform risk stratification. Prospective validation studies are needed.

Level of evidence

IV.

Trial registration number

NCT02119182.

Pre-injury psychiatric history, subacute symptoms and personality traits predict social reintegration at 3-month post-mild traumatic brain injury

BACKGROUND

The purpose of the study was to identify whether the presence of a pre-injury psychiatric history, subacute post-concussive symptoms (PCS) and personality traits were predictive of less favorable social reintegration for 3 months following a mild traumatic brain injury (mTBI).

METHOD

A total of 76 patients with mTBI were included, and the presence of a pre-injury psychiatric history was identified from the medical chart. One-month post-accident, these patients completed the Millon Multiaxial Clinical Inventory, 3rd Edition assessing personality traits and the Rivermead Post-Concussion Symptoms Questionnaire to measure subacute PCS. Social reintegration was measured using the Mayo-Portland Adaptability Inventory, 4th Edition at 3-month post-accident.

RESULTS

The presence of pre-injury psychiatric history, high levels of subacute PCS and Cluster B personality traits such as histrionic and borderline features were significant predictors of social reintegration quality at 3-month post injury.

CONCLUSION

This study provides new insights on cluster B personality traits and its influence on recovery and social reintegration at 3-month post mTBI.

"Alone in the dark": A qualitative study of treatment experiences among young adults with a recent concussion and anxiety

PURPOSE

Young adults with anxiety are vulnerable to developing persistent symptoms following concussions. In order to develop psychosocial interventions to prevent persistent post-concussion symptoms, we need to understand patients' 1) experiences with treatments offered by health care providers; 2) experiences with attempted concussion management strategies; and 3) needs after their injury.

METHODS

We conducted in-depth interviews with 17 young adults with recent (≤ 10 weeks) concussions who have at least mild anxiety (Generalized Anxiety Disorder Assessment-7 ≥ 5). We used a hybrid deductive-inductive approach to thematic analysis.

RESULTS

Findings provide insight into recommended treatments (e.g., active/avoidant strategies, accommodations, referrals), attempted strategies (e.g., lifestyle changes, pacing, relationships, acceptance-based coping skills), and patient needs (e.g., education, accommodations, referrals for cognitive and emotional skills). Participants frequently expressed that treatment recommendations were confusing and difficult to implement. They initiated non-prescribed strategies that helped promote recovery and expressed a desire for more interdisciplinary treatment and education on concussions.

CONCLUSION

Patients' perceptions of health care provider recommendations after concussions did not fully meet patients' perceived needs. Young adults with concussions and anxiety would benefit from more education, guidance, and psychosocial and rehabilitation services. Addressing these gaps may help align treatments with patients' needs and therefore help optimize their recovery.

Graded Exposure Therapy for Fear Avoidance Behaviour After Concussion (GET FAB): protocol for a multisite Canadian randomised controlled trial

INTRODUCTION

Persistent symptoms after mild traumatic brain injury (mTBI) negatively affect daily functioning and quality of life. Fear avoidance behaviour, a coping style in which people avoid or escape from activities or situations that they expect will exacerbate their symptoms, maybe a particularly potent and modifiable risk factor for chronic disability after mTBI. This study will evaluate the efficacy of graded exposure therapy (GET) for reducing persistent symptoms following mTBI, with two primary aims: (1) To determine whether GET is more effective than usual care; (2) to identify for whom GET is the most effective treatment option, by evaluating whether baseline fear avoidance moderates differences between GET and an active comparator (prescribed aerobic exercise). Our findings will guide evidence-based care after mTBI and enable better matching of mTBI patients to treatments.

METHODS AND ANALYSIS

We will conduct a multisite randomised controlled trial with three arms. Participants (n=220) will be recruited from concussion clinics and emergency departments in three Canadian provinces and randomly assigned (1:2:2 ratio) to receive enhanced usual care, GET or prescribed aerobic exercise. The outcome assessment will occur remotely 14-18 weeks following baseline assessment, after completing the 12-week treatment phase. The primary outcome will be symptom severity (Rivermead Post-concussion Symptoms Questionnaire).

ETHICS AND DISSEMINATION

Informed consent will be obtained from all participants. All study procedures were approved by the local research ethics boards (University of British Columbia Clinical Research Ethics Board, University of Calgary Conjoint Health Research Ethics Board, University Health Network Research Ethics Board-Panel D). Operational approvals were obtained for Vancouver Coastal Health Research Institute and Provincial Health Services Authority. If GET proves effective, we will disseminate the GET treatment manual and present instructional workshops for clinicians.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov #NCT05365776.

"I Wish I Had That!": A Qualitative Analysis of Psychosocial Treatment Preferences Among Young Adults With Recent Concussion and Anxiety

OBJECTIVE

To assess psychosocial treatment preferences and factors that may affect treatment participation among young adults with a recent concussion and co-occurring anxiety.

DESIGN

In-depth, semi-structured individual qualitative interviews, followed by thematic analysis using a hybrid deductive-inductive approach.

SETTING

Academic medical center in the US Northeast.

PARTICIPANTS

Seventeen young adults (18-24y) who sustained a concussion within the past 3-10 weeks and reported at least mild anxiety (≥5 on the Generalized Anxiety Disorder-7 questionnaire).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Primary outcomes include preferences for program content (eg, topics and skills), delivery modality, format, and barriers and facilitators to participation.

RESULTS

We identified 4 domains characterizing participants' perceptions of and preferences for treatment. (1) Program content: Participants preferred a program early after injury that included psychoeducation and coping skills (eg, activity pacing, deep breathing, mindfulness). (2) Therapeutic processes: Participants preferred a person-centered approach in which clinicians normalized anxiety postconcussion and reassured them of recovery. (3) Program logistics: Participants endorsed that a brief, virtual program would be acceptable. They preferred access to program components through multiple modalities (eg, audio, video) and accommodations to manage concussion symptoms. (4) Barriers and facilitators to participation: Barriers included acute concussion symptoms (eg, screen sensitivity), time constraints, and forgetting sessions. Facilitators included a program that is flexible (format, scheduling), personalized (self-chosen mode for reminders, measure of accountability), and accessible (ie, advertising through health care professionals or social media).

CONCLUSIONS

Participants need psychosocial support that normalizes their experiences and provides education and coping tools. Treatments should be accessible, flexible, and person centered. Psychosocial treatments meeting these preferences may help optimize the recovery of young adults with recent concussion and anxiety.

Return to work in persons with persistent postconcussion symptoms: a survey study examining the perspectives of employees and managers

OBJECTIVE

To examine challenges in return to work (RTW) for persons with persistent postconcussion symptoms (PPCS) experienced by the affected employees and their managers.

METHODS

A survey of employees (S-E) and two surveys of managers (S-M1, S-M2) executed 4 months apart to capture the time perspective. Inclusion: Adults aged 18-66 with PPCS > 4 weeks, employed at the time of mTBI who returned to work within the previous year. Managers involved in their RTW process.

OUTCOME MEASURES

Work status, working hours, work functioning (Work Role Functioning Questionnaire, WRFQ), work productivity.

RESULTS

Ninety-two employees and 66 managers were recruited. Three-fourths of the employees had returned to work but only one-third worked under similar conditions. Weekly working hours decreased from 36,3 hours (SD = 10,5) before mTBI to 17,6 hours (SD = 9,7). Employees had difficulties with tasks 43% of time (WRFQ). They needed more breaks, struggled with multitasking and work speed. About 65.9% experienced affected work productivity. Managers reported lack of knowledge and difficulties assessing the number of working hours and suitable tasks.

CONCLUSIONS

Most employees returned to work but only a minority worked under similar conditions as before mTBI. Employees and managers struggled to estimate workload. The affected employees and their workplaces need a long-term RTW support.

Altered pattern of theta and gamma oscillation to visual stimuli in patients with postconcussion syndrome

Although many patients with mild traumatic brain injury (mTBI) suffer from postconcussional syndrome (PCS) including abnormal emotional responses, most conventional imaging studies fail to detect any causative brain lesion. We hypothesized that event-related electroencephalography (EEG) recordings with time-frequency analysis would show a distinguishable pattern in patients with mTBI with PCS compared with normal healthy controls. EEG signals were collected from a total of 18 subjects: eight patients with mTBI with PCS and 10 healthy control subjects. The signals were recorded while the subjects were presented with affective visual stimuli, including neutral, pleasant, and unpleasant emotional cues. Event-related spectral perturbation analysis was performed to calculate frontal midline theta activity and posterior midline gamma activity, followed by statistical analysis to identify whether patients with mTBI with PCS have distinct patterns of theta or gamma oscillations in response to affective stimuli. Compared with the healthy control group, patients with mTBI with PCS did not show a significant increase in the power of frontal theta activity in response to the pleasant stimuli, indicating less susceptibility toward pleasant cues. Moreover, the patient group showed attenuated gamma oscillatory activity, with no clear alteration in gamma oscillations in response to either pleasant or unpleasant cues. This study demonstrates that patients with mTBI with PCS exhibited altered patterns of oscillatory activities in the theta and gamma bands in response to affective visual stimuli compared with the normal control group. The current finding implicates that these distinguishable patterns of brain oscillation may represent the mechanism behind various psychiatric symptoms in patients with mTBI.NEW & NOTEWORTHY Patients with mild traumatic brain injury (mTBI) with postconcussional syndrome (PCS) exhibited altered patterns of changes in oscillatory activities in the theta and gamma bands in response to visual affective stimuli. Distinguishable patterns of brain oscillation may represent the mechanism behind various psychiatric symptoms in patients with mTBI.

Cause of Concussion With Persisting Symptoms Is Associated With Long-Term Recovery and Symptom Type, Duration, and Number in a Longitudinal Cohort of 600 Patients

It is important for patients and clinicians to know the potential for recovery from concussion as soon as possible after injury, especially in patients who do not recover completely in the first month and have concussion with persisting concussion symptoms (C+PCS). We assessed the association between the causes of concussion and recovery from C+PCS in a consecutive retrospective and prospective cohort of 600 patients referred to the Canadian Concussion Center (CCC) at Toronto Western Hospital. Data were obtained from clinical records and follow-up questionnaires and not from a standardized database. A novel method was used to assess long-term recovery, and multi-variable Cox proportional hazards models were used to assess relationships between cause of concussion and time to recovery. We examined the subsequent recovery of patients who had not recovered after at least one month from the time of concussion. Patients were grouped into the following four causes: sports and recreation (S&R, n = 312, 52%); motor vehicle collisions (MVC, n = 103, 17%); falls (n = 100, 17%); and being struck by an object including violence (SBOV, n = 85, 14%). The MVC group had the highest percentage of females (75.7%), the oldest participants (median: 40.0 [interquartile range (IQR):30.5-49.0] years), the most symptoms (median:11.0 [IQR:8.5-15.0]), and the longest symptom duration (median: 28.0 [IQR:12.0-56.00] months). In contrast, the S&R group had the highest percentage of males (58.1%), the youngest participants (median:20.0 [IQR:17.0-30.0] years), the best recovery outcome, and shortest symptom duration (median:22.0 [IQR:8.0-49.5] months). Significant differences among the four causes included age (p < 0.001), sex (p < 0.001), number of previous concussions (p < 0.001), history of psychiatric disorders (p = 0.002), and migraine (p = 0.001). Recovery from concussion was categorized into three groups: (1) Complete Recovery occurred in only 60 (10%) patients with median time 8.0 (IQR:3.5-18.0) months and included 42 S&R, 7 MVC, 8 falls, and 3 SBOV; (2) Incomplete Recovery occurred in 408 (68.0%) patients with persisting median symptom time of 5.0 (IQR:2.0-12.0) months; and (3) Unknown Recovery occurred in 132 (22.0%) patients and was because of lack of follow-up. In summary, the cause of C+PCS was associated with the type, number, and duration of symptoms and time required for recovery, although all causes of C+PCS produced prolonged symptoms in a large percentage of patients, which emphasizes the importance of concussions as a public health concern necessitating improved prevention and treatment strategies.

Co-existence of depression and post-concussion syndrome one month after mild traumatic brain injury

BACKGROUND

Previous studies suggest an association between Post-concussion syndrome (PCS) and depression, both highly prevalent after mTBI.

OBJECTIVE

To assess the prevalence and risk-factors of depression among patients with PCS 1 month after mTBI.

METHODS

We prospectively screened 372 mTBI patients admitted in two academic Emergency Departments between 2017 and 2019. One month after mTBI, we administered the Rivermead Post-concussion symptoms Questionnaire (RPQ) and the Patient Health Questionnaire (PHQ-9) questionnaires over the telephone. PCS and depression were defined by RPQ ≥ 12 and PHQ-9 ≥ 10. Multivariate multinomial regression identified baseline factors associated with PCS and depression.

RESULTS

Two hundred and eight completed RPQ and PHQ-9. Forty-seven patients (22.5%) met criteria for PCS, among which 22 (46.8%) met criteria for depression (PCS+D+). Patients with PCS but without depression were less likely to present with an associated injury (Coefficient = -1.6, p = 0.047) and to report initial sadness (Coefficient = -2.5, p = 0.03). Initial sadness (Coefficient = -1.3, p = 0.047), associated injury (Coefficient = -1.9, p = 0.008), as well as initial nausea (Coefficient = -1.8, p = 0.002), and male sex (Coefficient = 1.8, p = 0.002), were associated with the absence of depression and PCS in comparison with PCS+D+ patients.

CONCLUSION

Among patients with PCS 1 month after mTBI, those with depression are more likely to present with initial sadness and with an associated injury.

Athlete Fear Avoidance, Depression, and Anxiety Are Associated with Acute Concussion Symptoms in Athletes

Background: Assessing sport-related concussions in athletes presents challenges due to symptom variability. This study aimed to explore the relationship between acute concussion symptoms and athlete fear avoidance, pain catastrophizing, depression, and anxiety. Anxiety and depression have previously been associated with the number of symptoms after a concussion, but no prior research has examined the possible link between athlete fear avoidance and acute concussion symptoms. Methods: Thirty-four collegiate athletes (mean age = 20.9 ± 1.8 years) were assessed within 48 h of a concussion using the Sport Concussion Assessment Tool 5, Athlete Fear Avoidance Questionnaire (AFAQ), Pain Catastrophizing Scale, and Hospital Anxiety and Depression Scale. Results: Results showed a significant association between the athlete fear avoidance and the number of concussion symptoms (r = 0.493, p = 0.003), as well as depression and anxiety measured by HADS (r = 0.686, p < 0.001). Athlete fear avoidance and HADS scores were predictors of symptom severity, explaining 41% of the variance (p = 0.001). Athletes with higher fear avoidance tended to report more symptoms post concussion. Conclusions: This study underscores the link between athlete fear avoidance, anxiety, depression, and the severity of concussion symptoms. Administering the AFAQ to assess athlete fear avoidance at the initial assessment of a concussion may be helpful in interpreting the symptoms of an acute concussion.

Evaluating the utility of quantitative pupillometry in a neuro-critical care setting for the monitoring of intracranial pressure: A prospective cohort study

INTRODUCTION

Assessment of the pupillary light reflex (PLR) is key in intensive care monitoring of neurosurgical patients, particularly for monitoring intracranial pressure (ICP). Quantitative pupillometry using a handheld pupillometer is a reliable method for PLR assessment. However, many variables are derived from such devices. We therefore aimed to assess the performance of these variables at monitoring ICP.

METHODS

Sedated patients admitted to neurocritical care in a tertiary neurosurgical centre with invasive ICP monitoring were included. Hourly measurement of ICP, subjective pupillometry (SP) using a pen torch device, and quantitative pupillometry (QP) using a handheld pupillometer were performed.

RESULTS

561 paired ICP, SP and QP pupillary observations from nine patients were obtained (1122 total pupillary observations). SP and QP had a moderate concordance for pupillary size (κ=0.62). SP performed poorly at detecting pupillary size changes (sensitivity=24%). In 40 (3.6%) observations, SP failed to detect a pupillary response whereas QP did. Moderate correlations with ICP were detected for maximum constriction velocity (MCV), dilation velocity (DV), and percentage change in pupillary diameter (%C). Discriminatory ability at an ICP threshold of >22 mmHg was moderate for MCV (AUC=0.631), DV (AUC=0.616), %C (AUC=0.602), and pupillary maximum size (AUC=0.625).

CONCLUSION

QP is superior to SP at monitoring pupillary reactivity and changes to pupillary size. Although effect sizes were moderate to weak across assessed variables, our data indicates MCV and %C as the most sensitive variables for monitoring ICP. Further study is required to validate these findings and to establish normal range cut-offs for clinical use.

Prevalence of fatigue and cognitive impairment after traumatic brain injury

BACKGROUND

Following traumatic brain injury (TBI) some patients develop lingering comorbid symptoms of fatigue and cognitive impairment. The mild cognitive impairment self-reported by patients is often not detected with neurocognitive tests making it difficult to determine how common and severe these symptoms are in individuals with a history of TBI. This study was conducted to determine the relative prevalence of fatigue and cognitive impairment in individuals with a history of TBI.

METHODS

The Fatigue and Altered Cognition Scale (FACs) digital questionnaire was used to assess self-reported fatigue and cognitive impairment. Adults aged 18-70 were digitally recruited for the online anonymous study. Eligible participants provided online consent, demographic data, information about lifetime TBI history, and completed the 20 item FACs questionnaire.

RESULTS

A total of 519 qualifying participants completed the online digital study which included 204 participants with a history of TBI of varied cause and severity and 315 with no history of TBI. FACs Total Score was significantly higher in the TBI group (57.7 ± 22.2) compared to non-TBI (39.5 ± 23.9; p<0.0001) indicating more fatigue and cognitive impairment. When stratified by TBI severity, FACs score was significantly higher for all severity including mild (53.9 ± 21.9, p<0.0001), moderate (54.8 ± 24.4, p<0.0001), and severe (59.7 ± 20.9, p<0.0001) TBI. Correlation analysis indicated that more severe TBI was associated with greater symptom severity (p<0.0001, r = 0.3165). Ancillary analysis also suggested that FACs scores may be elevated in participants with prior COVID-19 infection but no history of TBI.

CONCLUSIONS

Adults with a history of even mild TBI report significantly greater fatigue and cognitive impairment than those with no history of TBI, and symptoms are more profound with greater TBI severity.

Valued living after mild traumatic brain injury: Characteristics and relationship with outcomes

Psychological factors are strong predictors of mild traumatic brain injury (mTBI) recovery, consequently, psychological interventions can form part of an individual's rehabilitation. This may include enhancing valued living (VL), an approach that is effective in severe and mixed acquired brain injury samples. This study aimed to characterize VL in mTBI and explore its relationship with mTBI and mental health outcomes. 56 participants with a mTBI completed self-report measures before engaging in a psychological intervention. Pre-injury mental health and other demographic and injury-related variables, VL, post-concussion symptoms (PCS), functional disability, and stress, anxiety and depression were measured. A pre-injury mental health condition was significantly associated with VL. VL was uniquely associated with depression after mTBI (β = -0.08, p = .05), however, there was no relationship with PCS, functional disability, stress or anxiety (p > .05). Following mTBI individuals with a pre-injury mental health condition or who experience heightened depressive symptoms may benefit from a values-based intervention as part of their rehabilitation. Future research, however, is needed to examine the role of VL in mTBI recovery.

External Validation of the Post-Concussion Symptoms Rule for Predicting Mild Traumatic Brain Injury Outcome

Persistent symptoms are common after a mild traumatic brain injury (mTBI). The Post-Concussion Symptoms (PoCS) Rule is a newly developed clinical decision rule for the prediction of persistent post-concussion symptoms (PPCS) 3 months after an mTBI. The PoCS Rule includes assessment of demographic and clinical characteristics and headache presence in the emergency department (ED), and follow-up assessment of symptoms at 7 days post-injury using two thresholds (lower/higher) for symptom scoring. We examined the PoCS Rule in an independent sample. We analyzed a clinical trial that recruited participants with mTBI from EDs in Greater Vancouver, Canada. The primary analysis used data from 236 participants, who were randomized to a usual care control group, and completed the Rivermead Postconcussion Symptoms Questionnaire at 3 months. The primary outcome was PPCS, as defined by the PoCS authors. We assessed the overall performance of the PoCS rule (area under the receiver operating characteristic curve [AUC]), sensitivity, and specificity. More than 40% of participants (median age 38 years, 59% female) reported PPCS at 3 months. Most participants (88%) were categorized as being at medium risk based on the ED assessment, and a majority were considered as being at high risk according to the final PoCS Rule (81% using a lower threshold and 72% using a higher threshold). The PoCS Rule showed a sensitivity of 93% (95% confidence interval [CI], 88-98; lower threshold) and 85% (95% CI, 78-92; higher threshold), and a specificity of 28% (95% CI, 21-36) and 37% (95% CI, 29-46), respectively. The overall performance was modest (AUC 0.61, 95% CI 0.59, 0.65). In conclusion, the PoCS Rule was sensitive for PPCS, but had a low specificity in our sample. Follow-up assessment of symptoms can improve risk stratification after mTBI.

Head Injury Due to Intimate Partner Violence: Injury Characteristics, Subacute Symptoms, and Receipt of Care

Women survivors of intimate partner violence (IPV) have increased risk of repetitive neurotrauma in their lifetime but have received less research focus compared with populations of athletes, veterans, and emergency department patients. The current study examined the importance of IPV as a contextual mechanism of injury, by comparing women survivors of IPV based on whether they experienced a head injury due to IPV or a head injury not due to IPV. The analyses involved archival data from in-person interviews conducted with women who received a protective order against an intimate partner in Kentucky from 2001 to 2004 (n = 641). Women were excluded if they reported no head injury history (n = 268), resulting in two groups compared based on a retrospective cohort design: 255 women with at least one self-reported IPV-related head injury (M = 33.8 ± 9.0 years old, range: 19-65; 87.5% White) and 118 women with self-reported head injuries due to reasons other than IPV (M = 32.2 ± 9.1 years old, range: 18-62; 89.0% White). Participants were compared on injury characteristics, lifetime physical and sexual IPV severity, subacute symptoms of head injury, and receipt of care for head injury. Compared with women with head injuries unrelated to IPV, women with IPV-related head injuries reported a higher number of lifetime head injuries (Mdn[range]: IPV-related = 3[1-515] vs. non-IPV-related = 1[1-13], p < 0.001, r = 0.51) and a higher number of head injuries involving loss of consciousness (Mdn[range]: IPV-related = 1[1-35] vs. non-IPV-related = 1[1-4], p < 0.001, r = 0.27), but lower rates of hospitalization (IPV-related = 56.1% vs. non-IPV-related = 73.7%, p = 0.001, odds ratio [OR] = 2.20 [95% confidence interval (CI): 1.36, 3.55]) and formal rehabilitation (IPV-related = 3.2% vs. non-IPV-related = 9.4%, p = 0.011, OR = 3.18 [1.24, 8.13]) following head injury. Women with IPV-related head injuries had greater lifetime severity of physical IPV (p < 0.001, d = 0.64 [0.41, 0.86]) and sexual IPV (p < 0.001, d = 0.38 [0.16, 0.60]). Women with IPV-related head injuries endorsed all symptoms at greater rates than women with non-IPV-related head injuries (ps < 0.001), including physical (e.g., headaches: OR = 3.15 [1.81, 5.47]; dizziness: OR = 2.65 [1.68, 4.16]), cognitive (e.g., trouble problem solving: OR = 2.66 [1.53, 4.64]; inattention: OR = 2.39 [1.52, 3.78]), and emotional symptoms (e.g., depression: OR = 7.39 [4.48, 12.20]; anxiety: OR = 4.60 [2.82, 7.51]). The total count of symptoms endorsed was higher for women with IPV-related head injury than women with head injuries unrelated to IPV (p < 0.001, d = 0.71 [0.49, 0.94]). When controlling for lifetime physical and sexual IPV, IPV-related head injury was independently associated with symptom count (β = 0.261, p < 0.001) and accounted for additional variance in symptom count (ΔR2 = 0.06, p < 0.001). Among women survivors of IPV, those reporting IPV-related head injuries reported greater subacute symptoms, but a lower likelihood of being hospitalized or receiving rehabilitative care. Women with self-reported IPV-related head injuries represent an underserved population that is often unevaluated following injury and may have many unmet care needs. Future studies should examine persistent symptoms following IPV-related head injuries and interventions that would be most beneficial for this population.

Acceptability, usability, and credibility of a mindfulness-based digital therapeutic for pediatric concussion: A mixed-method study

Background

The ability to cope with concussion symptoms and manage stress is an important determinant of risk for prolonged symptoms.

Objective

This open-label mixed-methods pilot study assessed the acceptability and credibility of a mindfulness-based intervention delivered through a digital therapeutic (DTx; therapeutic smartphone app) for pediatric concussion.

Methods

Participants aged 12 to 18 years were recruited from an emergency department within 48 hours of a concussion (acute cohort) or from a tertiary care clinic at least 1-month post-concussion (persisting symptoms cohort). Participants completed a novel 4-week mindfulness-based intervention, for 10 to 15 minutes/day, at a minimum of 4 days/week. At 2 weeks, participants completed a credibility and expectancy questionnaire. At 4 weeks, participants completed questionnaires assessing satisfaction, usability and working alliance, as well as a semi-structured phone interview.

Results

Ten participants completed the study outcomes (7 acute; 3 persisting symptoms). The intervention was perceived as credible (median/max possible = 6.50/9.00 [6.83,8.75]) and DTx was usable (median/max possible = 70.00/100.00 [55.00,82.50]). Participants rated their satisfaction with the DTx (median/max possible = 27.00/32.00 [24.50,29.50]) and the working alliance with the digital mindfulness guides (median/max possible = 3.92/5.00 [3.38-4.33]) as high. Four themes were identified from the qualitative data: (a) positive attributes; (b) negative attributes; (c) ideas for modifications; and (d) technical issues.

Conclusion

Results show modifications to the DTx, instructions and mindfulness intervention, and potential ways to increase adherence by leveraging positive attributes. A randomized control trial will assess the effectiveness of the DTx MBI to decrease the risk of persisting symptoms and reduce the symptom burden following pediatric concussion.

Medical Care Among Individuals with a Concussion in Ontario: A Population-based Study

BACKGROUND

Concussion affects 1.2% of the population annually; rural regions and children have higher rates of concussion.

METHODS

Using administrative health care linked databases, all residents of Ontario with a physician diagnosed concussion were identified using ICD-9 code 850 or ICD-10 code S06. Cases were tracked for 2 years for concussion-related health care utilization with relevant specialist physicians (i.e., neurology, otolaryngology, physiatry, psychiatry, ophthalmology). Billing codes, specialist codes, and time from index to visit were analyzed. Factors associated with increased specialist visits were also examined.

RESULTS

In total, 1,022,588 cases were identified between 2008 and 2014 with 2 years of post-concussion health care utilization available. Follow-up by physician within 3 days of injury occurred in only 14% of cases. Mean time between ED diagnosis and follow-up by a physician was 83.9 days, whereas for rural regions it was >100 days. About half of adults (51.9%) and children (50.3%) had at least 1 specialist visit following concussion. Mean time between injury and first specialist visit was 203.8 (SD 192.9) days for adults, 213.5 (SD 201.0) days for rural adults, and 276.0 (SD 202.6) days for children. There were 67,420 neurology visits, 70,404 psychiatry visits, 13,571 neurosurgery visits, 19,780 physiatry visits, 101,788 ENT visits, and 103,417 ophthalmology visits in the 2 years tracking period. Factors associated with more specialist use included age > 18 years, urban residence, and pre-injury psychiatric history.

CONCLUSIONS

There are discrepancies in post-concussion health care utilization based on age group and rural/urban residence. Addressing these risk factors could improve concussion care access.

Specialist healthcare services for concussion/mild traumatic brain injury in England: a consensus statement using modified Delphi methodology

OBJECTIVE

To establish a consensus on the structure and process of healthcare services for patients with concussion in England to facilitate better healthcare quality and patient outcome.

DESIGN

This consensus study followed the modified Delphi methodology with five phases: participant identification, item development, two rounds of voting and a meeting to finalise the consensus statements. The predefined threshold for agreement was set at ≥70%.

SETTING

Specialist outpatient services.

PARTICIPANTS

Members of the UK Head Injury Network were invited to participate. The network consists of clinical specialists in head injury practising in emergency medicine, neurology, neuropsychology, neurosurgery, paediatric medicine, rehabilitation medicine and sports and exercise medicine in England.

PRIMARY OUTCOME MEASURE

A consensus statement on the structure and process of specialist outpatient care for patients with concussion in England.

RESULTS

55 items were voted on in the first round. 29 items were removed following the first voting round and 3 items were removed following the second voting round. Items were modified where appropriate. A final 18 statements reached consensus covering 3 main topics in specialist healthcare services for concussion; care pathway to structured follow-up, prognosis and measures of recovery, and provision of outpatient clinics.

CONCLUSIONS

This work presents statements on how the healthcare services for patients with concussion in England could be redesigned to meet their health needs. Future work will seek to implement these into the clinical pathway.

Lack of association between four biomarkers and persistent post-concussion symptoms after a mild traumatic brain injury

Approximately 15 % of individuals who sustained a mild Traumatic Brain Injury (TBI) develop persistent post-concussion symptoms (PPCS). We hypothesized that blood biomarkers drawn in the Emergency Department (ED) could help predict PPCS. The main objective of this project was to measure the association between four biomarkers and PPCS at 90 days post mild TBI. We conducted a prospective cohort study in seven Canadian EDs. Patients aged ≥ 14 years presenting to the ED within 24 h of a mild TBI who were discharged were eligible. Clinical data and blood samples were collected in the ED, and a standardized questionnaire was administered 90 days later to assess the presence of symptoms. The following biomarkers were analyzed: S100B protein, Neuron Specific Enolase (NSE), cleaved-Tau (c-Tau) and Glial Fibrillary Acidic Protein (GFAP). The primary outcome measure was the presence of PPCS at 90 days after trauma. Relative risks and Areas Under the Curve (AUC) were computed. A total of 595 patients were included, and 13.8 % suffered from PPCS at 90 days. The relative risk of PPCS was 0.9 (95 % CI: 0.5-1.8) for S100B ≥ 20 pg/mL, 1.0 (95 % CI: 0.6-1.5) for NSE ≥ 200 pg/mL, 3.4 (95 % CI: 0.5-23.4) for GFAP ≥ 100 pg/mL, and 1.0 (95 % CI: 0.6-1.8) for C-Tau ≥ 1500 pg/mL. AUC were 0.50, 0.50, 0.51 and 0.54, respectively. Among mild TBI patients, S100B protein, NSE, c-Tau or GFAP do not seem to predict PPCS. Future research testing of other biomarkers is needed to determine their usefulness in predicting PPCS.

Proteomic discovery of prognostic protein biomarkers for persisting problems after mild traumatic brain injury

Some individuals with mild traumatic brain injury (mTBI), also known as concussion, have neuropsychiatric and physical problems that last longer than a few months. Symptoms following mTBI are not only impacted by the kind and severity of the injury but also by the post-injury experience and the individual's responses to it, making the persistence of mTBI particularly difficult to predict. We aimed to identify prognostic blood-based protein biomarkers predicting 6-month outcomes, in light of the clinical course after the injury, in a longitudinal mTBI cohort (N = 42). Among 420 target proteins quantified by multiple-reaction monitoring-mass spectrometry assays of blood samples, 31, 43, and 15 proteins were significantly associated with the poor recovery of neuropsychological symptoms at < 72 h, 1 week, and 1 month after the injury, respectively. Sequential associations among clinical assessments (depressive symptoms and cognitive function) affecting the 6-month outcomes were evaluated. Then, candidate biomarker proteins indirectly affecting the outcome via neuropsychological symptoms were identified. Using the identified proteins, prognostic models that can predict the 6-month outcome of mTBI were developed. These protein biomarkers established in the context of the clinical course of mTBI may have potential for clinical application.

Characterizing the profiles of patients with acute concussion versus prolonged post-concussion symptoms in Ontario

Identifying vulnerability factors for developing persisting concussion symptoms is imperative for determining which patients may require specialized treatment. Using cross-sectional questionnaire data from an Ontario-wide observational concussion study, we compared patients with acute concussion (≤ 14 days) and prolonged post-concussion symptoms (PPCS) (≥ 90 days) on four factors of interest: sex, history of mental health disorders, history of headaches/migraines, and past concussions. Differences in profile between the two groups were also explored. 110 patients with acute concussion and 96 patients with PPCS were included in our study. The groups did not differ on the four factors of interest. Interestingly, both groups had greater proportions of females (acute concussion: 61.1% F; PPCS: 66.3% F). Patient profiles, however, differed wherein patients with PPCS were significantly older, more symptomatic, more likely to have been injured in a transportation-related incident, and more likely to live outside a Metropolitan city. These novel risk factors for persisting concussion symptoms require replication and highlight the need to re-evaluate previously identified risk factors as more and more concussions occur in non-athletes and different risk factors may be at play.

Machine learning models to predict traumatic brain injury outcomes in Tanzania: Using delays to emergency care as predictors

Constraints to emergency department resources may prevent the timely provision of care following a patient's arrival to the hospital. In-hospital delays may adversely affect health outcomes, particularly among trauma patients who require prompt management. Prognostic models can help optimize resource allocation thereby reducing in-hospital delays and improving trauma outcomes. The objective of this study was to investigate the predictive value of delays to emergency care in machine learning based traumatic brain injury (TBI) prognostic models. Our data source was a TBI registry from Kilimanjaro Christian Medical Centre Emergency Department in Moshi, Tanzania. We created twelve unique variables representing delays to emergency care and included them in eight different machine learning based TBI prognostic models that predict in-hospital outcome. Model performance was compared using the area under the receiver operating characteristic curve (AUC). Inclusion of our twelve time to care variables improved predictability in each of our eight prognostic models. Our Bayesian generalized linear model produced the largest AUC, with a value of 89.5 (95% CI: 88.8, 90.3). Time to care variables were among the most important predictors of in-hospital outcome in our best three performing models. In low-resource settings where delays to care are highly prevalent and contribute to high mortality rates, incorporation of care delays into prediction models that support clinical decision making may benefit both emergency medicine physicians and trauma patients by improving prognostication performance.

Longitudinal Recovery Following Repetitive Traumatic Brain Injury

Importance

One traumatic brain injury (TBI) increases the risk of subsequent TBIs. Research on longitudinal outcomes of civilian repetitive TBIs is limited.

Objective

To investigate associations between sustaining 1 or more TBIs (ie, postindex TBIs) after study enrollment (ie, index TBIs) and multidimensional outcomes at 1 year and 3 to 7 years.

Design, Setting, and Participants

This cohort study included participants presenting to emergency departments enrolled within 24 hours of TBI in the prospective, 18-center Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study (enrollment years, February 2014 to July 2020). Participants who completed outcome assessments at 1 year and 3 to 7 years were included. Data were analyzed from September 2022 to August 2023.

Exposures

Postindex TBI(s).

Main Outcomes and Measures

Demographic and clinical factors, prior TBI (ie, preindex TBI), and functional (Glasgow Outcome Scale-Extended [GOSE]), postconcussive (Rivermead Post-Concussion Symptoms Questionnaire [RPQ]), psychological distress (Brief Symptom Inventory-18 [BSI-18]), depressive (Patient Health Questionnaire-9 [PHQ-9]), posttraumatic stress disorder (PTSD; PTSD Checklist for DSM-5 [PCL-5]), and health-related quality-of-life (Quality of Life After Brain Injury-Overall Scale [QOLIBRI-OS]) outcomes were assessed. Adjusted mean differences (aMDs) and adjusted relative risks are reported with 95% CIs.

Results

Of 2417 TRACK-TBI participants, 1572 completed the outcomes assessment at 1 year (1049 [66.7%] male; mean [SD] age, 41.6 [17.5] years) and 1084 completed the outcomes assessment at 3 to 7 years (714 [65.9%] male; mean [SD] age, 40.6 [17.0] years). At 1 year, a total of 60 participants (4%) were Asian, 255 (16%) were Black, 1213 (77%) were White, 39 (2%) were another race, and 5 (0.3%) had unknown race. At 3 to 7 years, 39 (4%) were Asian, 149 (14%) were Black, 868 (80%) were White, 26 (2%) had another race, and 2 (0.2%) had unknown race. A total of 50 (3.2%) and 132 (12.2%) reported 1 or more postindex TBIs at 1 year and 3 to 7 years, respectively. Risk factors for postindex TBI were psychiatric history, preindex TBI, and extracranial injury severity. At 1 year, compared with those without postindex TBI, participants with postindex TBI had worse functional recovery (GOSE score of 8: adjusted relative risk, 0.57; 95% CI, 0.34-0.96) and health-related quality of life (QOLIBRI-OS: aMD, -15.9; 95% CI, -22.6 to -9.1), and greater postconcussive symptoms (RPQ: aMD, 8.1; 95% CI, 4.2-11.9), psychological distress symptoms (BSI-18: aMD, 5.3; 95% CI, 2.1-8.6), depression symptoms (PHQ-9: aMD, 3.0; 95% CI, 1.5-4.4), and PTSD symptoms (PCL-5: aMD, 7.8; 95% CI, 3.2-12.4). At 3 to 7 years, these associations remained statistically significant. Multiple (2 or more) postindex TBIs were associated with poorer outcomes across all domains.

Conclusions and Relevance

In this cohort study of patients with acute TBI, postindex TBI was associated with worse symptomatology across outcome domains at 1 year and 3 to 7 years postinjury, and there was a dose-dependent response with multiple postindex TBIs. These results underscore the critical need to provide TBI prevention, education, counseling, and follow-up care to at-risk patients.

Early Measures of TBI Severity Poorly Predict Later Individual Impairment in a Rat Fluid Percussion Model

BACKGROUND

Multiple measures of injury severity are suggested as common data elements in preclinical traumatic brain injury (TBI) research. The robustness of these measures in characterizing injury severity is unclear. In particular, it is not known how reliably they predict individual outcomes after experimental TBI.

METHODS

We assessed several commonly used measures of initial injury severity for their ability to predict chronic cognitive outcomes in a rat lateral fluid percussion (LFPI) model of TBI. At the time of injury, we assessed reflex righting time, neurologic severity scores, and 24 h weight loss. Sixty days after LFPI, we evaluated working memory using a spontaneous alternation T-maze task.

RESULTS

We found that righting time and weight loss had no correlation to chronic T-maze performance, while neurologic severity score correlated weakly.

DISCUSSION

Taken together, our results indicate that commonly used early measures of injury severity do not robustly predict longer-term outcomes. This finding parallels the uncertainty in predicting individual outcomes in TBI clinical populations.

Prognostic Models for Global Functional Outcome and Post-Concussion Symptoms Following Mild Traumatic Brain Injury: A Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) Study

After mild traumatic brain injury (mTBI), a substantial proportion of individuals do not fully recover on the Glasgow Outcome Scale Extended (GOSE) or experience persistent post-concussion symptoms (PPCS). We aimed to develop prognostic models for the GOSE and PPCS at 6 months after mTBI and to assess the prognostic value of different categories of predictors (clinical variables; questionnaires; computed tomography [CT]; blood biomarkers). From the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study, we included participants aged 16 or older with Glasgow Coma Score (GCS) 13-15. We used ordinal logistic regression to model the relationship between predictors and the GOSE, and linear regression to model the relationship between predictors and the Rivermead Post-concussion Symptoms Questionnaire (RPQ) total score. First, we studied a pre-specified Core model. Next, we extended the Core model with other clinical and sociodemographic variables available at presentation (Clinical model). The Clinical model was then extended with variables assessed before discharge from hospital: early post-concussion symptoms, CT variables, biomarkers, or all three categories (extended models). In a subset of patients mostly discharged home from the emergency department, the Clinical model was extended with 2-3-week post-concussion and mental health symptoms. Predictors were selected based on Akaike's Information Criterion. Performance of ordinal models was expressed as a concordance index (C) and performance of linear models as proportion of variance explained (R2). Bootstrap validation was used to correct for optimism. We included 2376 mTBI patients with 6-month GOSE and 1605 patients with 6-month RPQ. The Core and Clinical models for GOSE showed moderate discrimination (C = 0.68 95% confidence interval 0.68 to 0.70 and C = 0.70[0.69 to 0.71], respectively) and injury severity was the strongest predictor. The extended models had better discriminative ability (C = 0.71[0.69 to 0.72] with early symptoms; 0.71[0.70 to 0.72] with CT variables or with blood biomarkers; 0.72[0.71 to 0.73] with all three categories). The performance of models for RPQ was modest (R2 = 4% Core; R2 = 9% Clinical), and extensions with early symptoms increased the R2 to 12%. The 2-3-week models had better performance for both outcomes in the subset of participants with these symptoms measured (C = 0.74 [0.71 to 0.78] vs. C = 0.63[0.61 to 0.67] for GOSE; R2 = 37% vs. 6% for RPQ). In conclusion, the models based on variables available before discharge have moderate performance for the prediction of GOSE and poor performance for the prediction of PPCS. Symptoms assessed at 2-3 weeks are required for better predictive ability of both outcomes. The performance of the proposed models should be examined in independent cohorts.

Network analysis applied to post-concussion symptoms in two mild traumatic brain injury samples

Objective

A latent disease explanation cannot exclusively explain post-concussion symptoms after mild traumatic brain injury (mTBI). Network analysis offers an alternative form of explanation for relationships between symptoms. The study aimed to apply network analysis to post-concussion symptoms in two different mTBI cohorts; an acute treatment-seeking sample and a sample 10 years post-mTBI.

Method

The treatment-seeking sample (n = 258) were on average 6 weeks post-injury; the 10 year post mTBI sample (n = 193) was derived from a population-based incidence and outcomes study (BIONIC). Network analysis was completed on post-concussion symptoms measured using the Rivermead Post-Concussion Questionnaire.

Results

In the treatment-seeking sample, frustration, blurred vision, and concentration difficulties were central to the network. These symptoms remained central in the 10 year post mTBI sample. A Network Comparison Test revealed evidence of a difference in network structure across the two samples (p = 0.045). However, the only symptoms that showed significant differences in strength centrality across samples were irritability and restlessness.

Conclusion

The current findings suggest that frustration, blurred vision and concentration difficulties may have an influential role in the experience and maintenance of post-concussion symptoms. The impact of these symptoms may remain stable over time. Targeting and prioritising the management of these symptoms may be beneficial for mTBI rehabilitation.

Prognostic factors for persistent symptoms in adults with mild traumatic brain injury: an overview of systematic reviews

BACKGROUND

Mild traumatic brain injury (mTBI) is an increasing public health problem, because of its persistent symptoms and several functional consequences. Understanding the prognosis of a condition is an important component of clinical decision-making and can help to guide the prevention of persistent symptoms following mTBI. The prognosis of mTBI has stimulated several empirical primary research papers and many systematic reviews leading to the identification of a wide range of factors. We aim to synthesize these factors to get a better understanding of their breadth and scope.

METHODS

We conducted an overview of systematic reviews. We searched in databases systematic reviews synthesizing evidence about the prognosis of persistent symptoms after mTBI in the adult population. Two reviewers independently screened all references and selected eligible reviews based on eligibility criteria. They extracted relevant information using an extraction grid. They also rated independently the risk of bias using the ROBIS tool. We synthesized evidence into a comprehensive conceptual map to facilitate the understanding of prognostic factors that have an impact on persistent post-concussion symptoms.

RESULTS

From the 3857 references retrieved in a database search, we included 25 systematic reviews integrating the results of 312 primary articles published between 1957 and 2019. We examined 35 prognostic factors from the systematics reviews. No single prognostic factor demonstrated convincing and conclusive results. However, age, sex, and multiple concussions showed an affirmatory association with persistent post-concussion outcomes in systematic reviews.

CONCLUSION

We highlighted the need for a comprehensive picture of prognostic factors related to persistent post-concussion symptoms. We believe that these prognostic factors would guide clinical decisions and research related to prevention and intervention regarding persistent post-concussion symptoms.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020176676.

Exploring the Association between Personality Traits, Symptom Burden, and Return to Work after Mild-to-Moderate Traumatic Brain Injury

Approximately 30% of individuals with mild traumatic brain injury (mTBI) experience persistent post-concussion symptoms (PPCS). Personality factors have been linked to PPCS, yet, the association between personality traits and outcomes after mTBI is poorly understood. The aim of this study was to evaluate the association between personality traits, PPCS, and return to work (RTW) in patients with mild-to-moderate traumatic brain injury (TBI). Data from eighty-seven participants with mild-to-moderate TBI were analyzed. Sociodemographic, injury, and work characteristics and depressive symptoms were recorded 2-3 months post-injury. Personality traits were measured using the NEO Five-Factor Inventory-3. PPCS and RTW were assessed 15 months post-injury. Multiple linear regression models were performed. The factors associated with more severe PPCS were female sex, higher levels of neuroticism, openness to experience and conscientiousness, extra-cranial injuries, and depressive symptoms. The factors associated with lower RTW were female sex, higher levels of neuroticism, and conscientiousness. However, after controlling for PPCS, personality traits were no longer significantly associated with RTW. In conclusion, specific personality traits were associated with more severe PPCS and may be indirectly associated with RTW via PPCS. Hence, personality traits may be important to assess to identify patients at risk of less favorable outcomes after mild-to-moderate TBI.

Factors related to adverse long-term outcomes after mild traumatic brain injury in children: a scoping review

OBJECTIVE

To identify demographic, premorbid and injury-related factors, or biomarkers associated with long-term (≥3 months) adverse outcomes in children after mild traumatic brain injury (mTBI).

DESIGN

Scoping review of literature.

PATIENTS

Children and adolescents with mTBI.

RISK FACTORS

Any demographic, premorbid and injury-related factors, or biomarkers were included. We excluded genetic and treatment-related factors.

MAIN OUTCOME MEASURES

Postconcussion syndrome (PCS), recovery.

RESULTS

Seventy-three publications were included, reporting 12 long-term adverse outcomes, including PCS in 12 studies and recovery in 29 studies. Additional outcomes studied were symptom scores/severity (n=22), quality of life (n=9) and cognitive function (n=9). Forty-nine risk factors were identified across studies. Risk factors most often assessed were sex (n=28), followed by age (n=23), injury mechanism = (n=22) and prior mTBI (n=18). The influence of these and other risk factors on outcomes of mTBI were inconsistent across the reviewed literature.

CONCLUSIONS

The most researched risk factors are sex, age and mechanism of injury, but their effects have been estimated inconsistently and did not show a clear pattern. The most studied outcomes are recovery patterns and symptom severity. However, these may not be the most important outcomes for clinicians and patients. Future primary studies in this area should focus on patient-important outcomes. Population-based prospective studies are needed that address prespecified hypotheses on the relationship of risk factors with given outcomes to enable reliable prediction of long-term adverse outcomes for childhood mTBI.

Identifying prioritization criteria for patients with mtbi waiting for multidisciplinary rehabilitation services: A Delphi study

INTRODUCTION

Rehabilitation service providers must take into account prognostic factors when making clinical decisions, which includes using these factors as prioritization criteria. The goal of this study was to establish consensus on patient prioritization criteria based on prognostic factors related to persistent symptoms for patients with mild traumatic brain injury (mTBI) waiting for outpatient specialized rehabilitation services.

MATERIALS AND METHODS

We conducted a Delphi survey involving clinicians, researchers, decision makers, and patients. Before the survey, we presented the results of an overview of systematic reviews summarizing the evidence on prognostic factors related to post-concussion symptoms.

RESULTS

After two rounds, the 17 experts reached consensus on the inclusion of 12 prioritization criteria: acute stress disorder, anxiety and depression, baseline mental and physical health, functional impacts and difficulties in performing daily habits after the trauma, motivation to receive services, multiple concussions, prior neurological problems, PTSD, quality of sleep, return to work failures, somatic complaints, suicidal ideation.

CONCLUSION

Healthcare stakeholders must consider a wide range of factors to guide clinical decision-making, including about access to care and patient prioritization. This study shows that the Delphi technique can be used to reach consensus on such decisions regarding patients with mTBI who are waiting for outpatient specialized rehabilitation services.

The influence of psychological flexibility on persistent post concussion symptoms and functional status after mild traumatic brain injury

PURPOSE

This study investigated the predictive role of psychological flexibility on long-term mTBI outcomes.

METHOD

Adults with mTBI (N = 147) completed a context specific measure of psychological flexibility, (AAQ-ABI), psychological distress, and mTBI outcomes at less than three months post injury (M = 6.02 weeks after injury) and 6 months later (N = 102). Structural equation modelling examined the mediating effects of psychological flexibility on psychological distress and mTBI outcomes at six months. The direct effect of psychological flexibility at less than three months on mTBI outcomes at six months was entered into the model, plus pre-injury and injury risk factors.

RESULTS

The theoretically derived model had good overall fit (χ2 = 1.42; p = 0.09; NFI = 0.95; TLI = 0.95; CFI = 0.98 and RMSEA = 0.06). Psychological flexibility at less than 3 months was directly significantly related to psychological distress and post-concussion symptoms at six months. Psychological flexibility at 6 months significantly mediated the relationship between psychological distress and functional disability but not post-concussion symptoms at six months post injury.

CONCLUSION

The exploratory findings suggest that a context specific measure of psychological flexibility assessed acutely and in the chronic phase of recovery may predict longer-term mTBI outcomes.Implications for RehabilitationPersistent post-concussion symptoms (PPCS) after mild traumatic brain injury (mTBI) can have a significant impact on wellbeing, functional status, and quality of life.In this study, psychological flexibility early in recovery, was associated with higher levels of psychological distress and more severe post-concussion symptoms six months later.Psychological flexibility at six months post-injury also mediated the relationship between psychological distress and functional disability.A context specific measure of psychological flexibility may predict poorer long-term outcomes following mTBI.

Psychological Contributions to Symptom Provocation Testing After Concussion

OBJECTIVE

Following concussion, symptoms such as headache, dizziness, and fatigue may transiently worsen or reemerge with increased exertion or activity. Standardized tests have been developed to assess symptom increases following aerobic, cognitive, or vestibular/oculomotor challenge. Although neurophysiological mechanisms are proposed to underlie symptom increases following exertion, psychological factors such as anxiety and misinterpretation of normal bodily sensations may also play a role. In this study, we examined the contribution of psychological factors to symptom provocation testing outcomes.

SETTING

Two outpatient concussion clinics in British Columbia, Canada.

PARTICIPANTS

Adults with persistent symptoms following concussion ( N = 79; 62% women).

DESIGN

In a single session, participants completed self-report questionnaires measuring the psychological factors of interest and underwent symptom provocation testing including aerobic (Buffalo Concussion Bike Test; BCBT), cognitive (National Institutes of Health Toolbox-Cognition Battery; NIHTB-CB), and vestibular/oculomotor (Vestibular/Ocular Motor Screening for Concussion; VOMS) challenge.

MAIN MEASURES

Psychological factors of interest included premorbid and current anxiety (Generalized Anxiety Disorder-7; GAD-7), catastrophizing (Pain Catastrophizing Scale-Adapted; PCS-A), fear avoidance behavior (Fear Avoidance Behavior after Traumatic Brain Injury; FAB-TBI), and somatization (Patient Health Questionnaire-15; PHQ-15). Our primary outcome variables were self-reported symptom change during each symptom provocation test.

RESULTS

We found that current anxiety ( B = 0.034; 95% CI = 0.003, 0.065), symptom catastrophizing ( B = 0.013; 95% CI = 0.000, 0.026), fear avoidance behavior ( B = 0.029; 95% CI = 0.008, 0.050), and somatization ( B = 0.041; 95% CI = 0.007, 0.075) were associated with increased symptoms during the VOMS in univariate models adjusted for time postinjury but not in a multivariable model that included all covariates. The psychological variables of interest were not significantly related to symptom change during the BCBT or NIHTB-CB.

CONCLUSION

Our findings suggest that symptom provocation test failure should be interpreted with caution because it might indicate psychological maladjustment rather than lingering brain injury or incomplete neurophysiological recovery.

Management of Psychological Complications Following Mild Traumatic Brain Injury

PURPOSE OF REVIEW

It has been clear for decades that psychological factors often contribute to mild traumatic brain injury (mTBI) outcome, but an emerging literature has begun to clarify which specific factors are important, when, for whom, and how they impact recovery. This review aims to summarize the contemporary evidence on psychological determinants of recovery from mTBI and its implications for clinical management.

RECENT FINDINGS

Comorbid mental health disorders and specific illness beliefs and coping behaviors (e.g., fear avoidance) are associated with worse recovery from mTBI. Proactive assessment and intervention for psychological complications can improve clinical outcomes. Evidence-based treatments for primary mental health disorders are likely also effective for treating mental health disorders after mTBI, and can reduce overall post-concussion symptoms. Broad-spectrum cognitive-behavioral therapy may modestly improve post-concussion symptoms, but tailoring delivery to individual psychological risk factors and/or symptoms may improve its efficacy. Addressing psychological factors in treatments delivered primarily by non-psychologists is a promising and cost-effective approach for enhancing clinical management of mTBI. Recent literature emphasizes a bio-psycho-socio-ecological framework for understanding mTBI recovery and a precision rehabilitation approach to maximize recovery. Integrating psychological principles into rehabilitation and tailoring interventions to specific risk factors may improve clinical management of mTBI.

Atypical symptom reporting after mild traumatic brain injury

OBJECTIVE

Early reporting of atypical symptoms following a mild traumatic brain injury (mTBI) may be an early indicator of poor prognosis. This study aimed to determine the percentage of people reporting atypical symptoms 1-month post-mTBI and explore links to recovery 12 months later in a community-dwelling mTBI sample.

METHODS

Adult participants (>16 years) who had experienced a mTBI were identified from a longitudinal incidence study (BIONIC). At 1-month post-injury, 260 participants completed the Rivermead Post-Concussion Symptoms Questionnaire (typical symptoms) plus four atypical symptom items (hemiplegia, difficulty swallowing, digestion problems and difficulties with fine motor tasks). At 12 months post-injury, 73.9% (n = 193) rated their overall recovery on a 100-point scale. An ordinal regression explored the association between atypical symptoms at 1 month and recovery at 12 months post-injury (low = 0-80, moderate = 81-99 and complete recovery = 100), whilst controlling for age, sex, rehabilitation received, ethnicity, mental and physical comorbidities and additional injuries sustained at the time of injury.

RESULTS

At 1-month post-injury <1% of participants reported hemiplegia, 5.4% difficulty swallowing, 10% digestion problems and 15.4% difficulties with fine motor tasks. The ordinal regression model revealed atypical symptoms were not significant predictors of self-rated recovery at 12 months. Older age at injury and higher typical symptoms at 1 month were independently associated with poorer recovery at 12 months, p < 0.01.

CONCLUSION

Atypical symptoms on initial presentation were not linked to global self-reported recovery at 12 months. Age at injury and typical symptoms are stronger early indicators of longer-term prognosis. Further research is needed to determine if atypical symptoms predict other outcomes following mTBI.

Relationship Between Neighborhood Disadvantage and Mild Traumatic Brain Injury Symptoms

OBJECTIVE

To test the hypotheses that (1) higher neighborhood disadvantage is associated with greater injury-related symptom severity in civilians with mild traumatic brain injury (mTBI) and (2) neighborhood disadvantage remains predictive after controlling for other established predictors.

SETTING

Level 1 trauma center and affiliated academic medical center.

PARTICIPANTS

N = 171 individuals with mTBI.

DESIGN

Prospective cohort study.

MAIN MEASURES

Rivermead Post Concussion Symptoms Questionnaire (RPQ) total score assessed less than 24 hours and at 2 weeks, 3 months, and 6 months postinjury. Linear mixed-effects models were used to assess the relationship between predictor variables and mTBI-related symptom burden (RPQ score). Neighborhood disadvantage was quantified by the Area Deprivation Index (ADI), a composite of 17 markers of socioeconomic position (SEP) scored at the census block group level.

RESULTS

Individuals in the upper ADI quartile of the national distribution displayed higher RPQ symptoms than those in the lower 3 quartiles ( P < .001), with a nonsignificant ADI × visit interaction ( P = .903). In a multivariable model, the effect of ADI remained significant ( P = .034) after adjusting for demographics, individual SEP, and injury factors. Other unique predictors in the multivariable model were gender (gender × visit P = .035), health insurance type ( P = .017), and injury-related litigation ( P = .012).

CONCLUSION

Neighborhood disadvantage as quantified by the ADI is robustly associated with greater mTBI-related symptom burden throughout the first 6 months postinjury. That the effect of ADI remained after controlling for demographics, individual SEP, and injury characteristics implies that neighborhood disadvantage is an important, understudied factor contributing to clinical recovery from mTBI.

Functional Recovery, Symptoms, and Quality of Life 1 to 5 Years After Traumatic Brain Injury

Importance

Many level I trauma center patients experience clinical sequelae at 1 year following traumatic brain injury (TBI). Longer-term outcome data are needed to develop better monitoring and rehabilitation services.

Objective

To examine functional recovery, TBI-related symptoms, and quality of life from 1 to 5 years postinjury.

Design, Setting, and Participants

This cohort study enrolled trauma patients across 18 US level I trauma centers between 2014 and 2018. Eligible participants were enrolled within 24 hours of injury and followed up to 5 years postinjury. Data were analyzed January 2023.

Exposures

Mild TBI (mTBI), moderate-severe TBI (msTBI), or orthopedic traumatic controls (OTC).

Main Outcomes and Measures

Functional independence (Glasgow Outcome Scale-Extended [GOSE] score 5 or higher), complete functional recovery (GOSE score, 8), better (ie, lower) TBI-related symptom burden (Rivermead Post Concussion Symptoms Questionnaire score of 15 or lower), and better (ie, higher) health-related quality of life (Quality of Life After Brain Injury Scale-Overall Scale score 52 or higher); mortality was analyzed as a secondary outcome.

Results

A total 1196 patients were included in analysis (mean [SD] age, 40.8 [16.9] years; 781 [65%] male; 158 [13%] Black, 965 [81%] White). mTBI and OTC groups demonstrated stable, high rates of functional independence (98% to 100% across time). While odds of independence were lower among msTBI survivors, the majority were independent at 1 year (72%), and this proportion increased over time (80% at 5 years; group × year, P = .005; independence per year: odds ratio [OR] for msTBI, 1.28; 95% CI, 1.03-1.58; OR for mTBI, 0.81; 95% CI, 0.64-1.03). For other outcomes, group differences at 1 year remained stable over time (group × year, P ≥ .44). Odds of complete functional recovery remained lower for persons with mTBI vs OTC (OR, 0.39; 95% CI, 0.28-0.56) and lower for msTBI vs mTBI (OR, 0.34; 95% CI, 0.24-0.48). Odds of better TBI-related symptom burden and quality of life were similar for both TBI subgroups and lower than OTCs. Mortality between 1 and 5 years was higher for msTBI (5.5%) than mTBI (1.5%) and OTC (0.7%; P = .02).

Conclusions and Relevance

In this cohort study, patients with previous msTBI displayed increased independence over 5 years; msTBI was also associated with increased mortality. These findings, in combination with the persistently elevated rates of unfavorable outcomes in mTBI vs controls imply that more monitoring and rehabilitation are needed for TBI.

Predictors of Social Participation Outcome after Traumatic Brain Injury Differ According to Rehabilitation Pathways

Social participation (SP) is one of many objectives in the rehabilitation of patients with traumatic brain injury (TBI). Studies on predictors of SP specific to post-acute universally accessible specialized rehabilitation pathways following TBI are scarce. Our objectives were to: 1) characterize SP, as well as a set of pre-injury, injury-related, and post-injury variables in individuals participating in inpatient-outpatient or outpatient rehabilitation pathways within a universally accessible and organized trauma continuum of care; and 2) examine the ability of pre-injury, injury-related, and post-injury variables in predicting SP outcome after TBI according to rehabilitation path. Participants (N = 372) were adults admitted to an inpatient-outpatient rehabilitation pathway or an outpatient rehabilitation pathway after sustaining a TBI between 2016 and 2020, and for whom Mayo-Portland Adaptability Intentory-4 (MPAI-4) outcomes were prospectively obtained at the start and end of rehabilitation. Additional data was collected from medical files. For both rehabilitation pathways, predicted SP outcome was MPAI-4 Participation score at discharge from outpatient rehabilitation. Multiple regression models investigated the predictive value of each variable for SP outcome, separately for each care pathway. Main findings show that for the inpatient-outpatient sample, three variables (education years, MPAI-4 Ability and Adjustment scores at rehabilitation intake) significantly predicted SP outcome, with the regression model accounting for 49% of the variance. For the outpatient sample, five variables (pre-morbid hypertension and mental health diagnosis, total indirect rehabilitation hours received, MPAI-4 Abilities and Adjustment scores at rehabilitation intake) significantly predicted SP outcome, with the regression model accounting for 47% of the variance. In conclusion, different pre-morbid and post-injury variables are involved in predicting SP, depending on the rehabilitation path followed. The predictive value of those variables could help clinicians identify patients more likely of showing poorer SP at discharge and who may require additional or different interventions.

Fear avoidance and return to work after mild traumatic brain injury

OBJECTIVES

Fear avoidance is associated with symptom persistence after mild traumatic brain injury (mTBI). In this study, we investigated whether fear avoidance was associated with other outcomes such as return to work-related activity (RTW).

MATERIALS AND METHODS

We analyzed associations between fear avoidance and RTW 6-9 months after mTBI, in two merged prospective mTBI cohorts. Adult participants aged 16 or over (n=175), presenting to outpatient services in New Zealand within 3 months of their injury, who were engaged in work-related activity at the time of injury, were included. Participants completed the Fear Avoidance Behavior after Traumatic Brain Injury (FAB-TBI) questionnaire at enrollment and 6 months later. Associations between FAB-TBI scores and RTW outcome were analyzed using multivariate approaches.

RESULTS

Overall, 53% of participants had RTW by 6-9 months after mTBI. While early fear avoidance was weakly associated with RTW, persistent high fear avoidance between study assessments or increasing avoidance with time were associated with greater odds of still being off work 6-9 months after injury.

CONCLUSIONS

Pervasive and increasing avoidance of symptom triggers after mTBI were associated with lower rates of RTW 6-9 months after mTBI. Further research is needed to better understand transition points along the recovery trajectory where fear avoidance behaviors fade or increase after mTBI.

Completing an interdisciplinary outpatient intervention improves patient rehabilitation goals following a mild traumatic brain injury

BACKGROUND

Individualized and interdisciplinary rehabilitation programs are recommended following a mild traumatic brain injury (mTBI), but often have long waitlists. Accordingly, innovative evidence-based programs are needed.

OBJECTIVES

The first objective of this study was to determine the number and types of rehabilitation goals chosen by individuals completing an interdisciplinary outpatient rehabilitation intervention (BrainEx90) for persisting symptoms following an mTBI. The second objective was to investigate whether completing BrainEx90 or choosing specific types of goals influenced performance and satisfaction ratings of these goals.

METHODS

217 individuals (44.4 ± 13.5 years old) with persisting symptoms following an mTBI completed BrainEx90, a 16-session interdisciplinary group outpatient rehabilitation intervention at Parkwood Institute between November 2013 and September 2019. Performance and satisfaction ratings of self-identified goals before and after BrainEx90 were assessed using the Canadian Occupational Performance Measure, and changes in ratings were analyzed using a linear mixed effects model.

RESULTS

1008 goals were identified and categorized as: productivity (45%); leisure (37%); and self-care (18%). Satisfaction ratings were significantly higher for all goal types following BrainEx90. Satisfaction with self-care goals improved significantly more than leisure [t(151) = 3.24, p < .01] and productivity [t(144) = 2.97, p < .01] goals. Performance ratings were also significantly greater following BrainEx90 [2.4, 95% CI [2.27, 2.53], p < .01)].

CONCLUSION

Performance and satisfaction of self-identified rehabilitation goals significantly improved following BrainEx90. Satisfaction with self-care goals demonstrated the greatest improvements, yet the most identified goal type was productivity.

Prediction Models for Neurocognitive Outcome of Mild Traumatic Brain Injury in Children: A Systematic Review

Mild traumatic brain injury (mTBI) is highly prevalent in children. Recent literature suggests that children with mTBI are at considerable risk of persisting neurocognitive deficits, threatening post-injury child development. Nevertheless, clinical tools for early identification of children at risk are currently not available. This systematic review aims to describe the available literature on neurocognitive outcome prediction models in children with mTBI. Findings are highly relevant for early identification of children at risk of persistent neurocognitive deficits, allowing targeted treatment of these children to optimize recovery. The electronic literature search was conducted in PubMed, EMBASE, CINAHL, Cochrane, PsychINFO and Web of Science on February 9, 2022. We included all studies with multi-variate models for neurocognitive outcome based on original data from only children (age <18 years) with mTBI. Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, two authors independently performed data extraction and risk of bias analysis using the Prediction model Risk of Bias Assessment Tool (PROBAST). This systematic review identified eight original studies (nine articles) reporting prediction models for neurocognitive outcome, representing a total of 1033 children diagnosed with mTBI (mean age at injury = 10.5 years, 37.6% girls). Neurocognitive outcome assessment took place between 1 month and 7 years post-injury. Models were identified with significant predictive value for the following outcomes: memory, working memory, inhibition, processing speed, and general neurocognitive functioning. Prediction performance of these models varied greatly between weak and substantial (R² = 10.0%-54.7%). The best performing model was based on demographic and pre-morbid risk factors in conjunction with a subacute neurocognitive screening to predict the presence of a deficit in general neurocognitive functioning at 12 months post-injury. This systematic review reflects the absence of robust prediction models for neurocognitive outcome of children with mTBI. The findings indicate that demographic factors, pre-morbid factors as well as acute and subacute clinical factors have relevance for neurocognitive outcome. Based on the available evidence, evaluation of demographic and pre-morbid risk factors in conjunction with a subacute neurocognitive screening may have the best potential to predict neurocognitive outcome in children with mTBI. The findings underline the importance of future research contributing to early identification of children at risk of persisting neurocognitive deficits.

Relationship between psychosocial and psychiatric risk factors and poor long-term outcome following mild traumatic brain injury: A systematic review

BACKGROUND AND PURPOSE

Mild traumatic brain injury (mTBI) has an estimated worldwide incidence of >60 million per year, and long-term persistent postconcussion symptoms (PPCS) are increasingly recognized as being predicted by psychosocial variables. Patients at risk for PPCS may be amenable to closer follow-up to treat modifiable symptoms and prevent chronicity. In this regard, similarities seem to exist with psychosocial risk factors for chronicity in other health-related conditions. However, as opposed to other conditions, no screening instruments exist for mTBI.

METHODS

A systematic search of the literature on psychological and psychiatric predictors of long-term symptoms in mTBI was performed by two independent reviewers using PubMed, Embase, and Web of Science.

RESULTS

Fifty papers were included in the systematic analysis. Anxiety, depressive symptoms, and emotional distress early after injury predict PPCS burden and functional outcome up to 1 year after injury. In addition, coping styles and preinjury psychiatric disorders and mental health also correlate with PPCS burden and functional outcome. Associations between PPCS and personality and beliefs were reported, but either these effects were small or evidence was limited.

CONCLUSIONS

Early psychological and psychiatric factors may negatively interact with recovery potential to increase the risk of chronicity of PPCS burden after mTBI. This opens opportunities for research on screening tools and early intervention in patients at risk.

Blood biomarkers of secondary outcomes following concussion: A systematic review

Introduction

Blood biomarkers have been identified as an alternative tool for predicting secondary outcomes following concussion. This systematic review aimed to summarize the literature on blood biomarkers of secondary outcomes following concussion in both pediatric and adult cohorts.

Methods

A literature search of Embase, Medline and PubMed was conducted. Two reviewers independently assessed retrieved studies to determine inclusion in systematic review synthesis.

Results

A total of 1771 unique studies were retrieved, 58 of which were included in the final synthesis. S100B, GFAP and tau were identified as being associated with secondary outcomes following concussion. Seventeen percent of studies were performed in a solely pediatric setting.

Conclusions

Validation of biomarkers associated with secondary outcomes following concussion have been largely limited by heterogeneous study cohorts and definitions of concussion and mTBI, presenting a hurdle for translation of these markers into clinical practice. Additionally, there was an underrepresentation of studies which investigated pediatric cohorts. Adult markers are not appropriate for children, therefore pediatric specific markers of secondary outcomes following concussion present the biggest gap in this field.

The importance of screening for functional neurological disorders in patients with persistent post-concussion symptoms

BACKGROUND

Functional neurological disorder (FND) may commonly co-occur with persistent symptoms following a psychological trauma or physical injury such as concussion.

OBJECTIVE

To explore the occurrence of FND in a population with persistent post-concussion symptoms (PPCS) and the associations between FND and depression as well as anxiety in participants with PPCS.

METHODS

Sixty-three individuals with PPCS presenting to a specialized brain injury clinic completed the following questionnaires: screening for somatoform disorder conversion disorder subscale (SOM-CD), Rivermead post-concussion symptom questionnaire (RPQ), patient health questionnaire-9 (PHQ-9), and generalized anxiety disorder questionnaire- 7 (GAD-7). Both multiple linear regression and logistic regression were conducted to evaluate the relationship between questionnaires and adjust for covariates.

RESULTS

We found that total RPQ score (βˆ= 0.27; 95% CI = [0.16, 0.38]), GAD-7 score (βˆ= 0.71; 95% CI = [0.50, 0.92]) and PHQ-9 score (βˆ= 0.54; 95% CI = [0.32, 0.76]) were positively associated with SOM-CD score individually, after consideration of other covariates. Participants meeting the criteria for severe FND symptoms were 4.87 times more likely to have high PPCS symptom burden (95% CI = [1.57, 22.84]), 8.95 times more likely to have severe anxiety (95% CI = [3.31, 35.03]) and 4.11 times more likely to have severe depression symptom burden (95% CI = [1.77, 11.53]).

CONCLUSION

The findings of this study indicate an association between FND and post-concussion symptoms as well as an association between FND and symptoms of depression and anxiety in patients with PPCS. Patients with PPCS should be screened for FND to provide a more targeted treatment approach that includes somatic-focused interventions.

Usability evaluation of a self-management mobile application for individuals with a mild traumatic brain injury

Objective

Mild traumatic brain injuries (mTBIs) are common and may result in persisting symptoms. Mobile health (mHealth) applications enhance treatment access and rehabilitation. However, there is limited evidence to support mHealth applications for individuals with an mTBI. The primary purpose of this study was to evaluate user experiences and perceptions of the Parkwood Pacing and Planning™ application, an mHealth application developed to help individuals manage their symptoms following an mTBI. The secondary purpose of this study was to identify strategies to improve the application. This study was conducted as part of the development process for this application.

Methods

A mixed methods co-design encompassing an interactive focus group and a follow-up survey was conducted with patient and clinician-participants (n = 8, four per group). Each group participated in a focus group consisting of an interactive scenario-based review of the application. Additionally, participants completed the Internet Evaluation and Utility Questionnaire (UQ). Qualitative analysis on the interactive focus group recordings and notes was performed using phenomenological reflection through thematic analyses. Quantitative analysis included descriptive statistics of demographic information and UQ responses.

Results

On average, clinician and patient-participants positively rated the application on the UQ (4.0 ± .3, 3.8 ± .2, respectively). User experiences and recommendations for improving the application were categorized into four themes: simplicity, adaptability, conciseness, and familiarity.

Conclusion

Preliminary analyses indicates patients and clinicians have a positive experience when using the Parkwood Pacing and Planning™ application. However, modifications that improve simplicity, adaptability, conciseness, and familiarity may further improve the user's experience.

Post-concussion symptoms 1-year after traumatic brain injury: using the Rivermead Post-concussion Questionnaire to identify predictors of severity

BACKGROUND

Patients who suffer traumatic brain injury (TBI) often experience a constellation of physical, cognitive, and emotional/behavioral symptoms called "post-concussion symptoms" and subsequent long-term disability. This study aimed to investigate the incidence of persistent post-concussion symptoms and possible predictors of long-term disability focusing on demographic, injury, and psychological factors. It was hoped to identify groups at high risk.

METHODS

A prospective cohort of 1322 individuals admitted with TBI were assessed in a specialist neurorehabilitation clinic at 10 weeks and 1-year post injury between August 2011 and July 2015. The outcome (post-concussion symptoms) was measured using the Rivermead Post-concussion Questionnaire (RPQ) at 1-year post injury.

RESULTS

At 1 yr, 1131 individuals were identified (>90% follow-up). Over 20% exhibited moderate or severe symptom levels on RPQ. A linear regression model showed that previous psychiatric history, lower Glasgow Coma Scale (GCS), severe CT abnormalities, injury caused by assault, pre-injury unemployment, and inability to return to work at 6 weeks post-injury were associated with worse symptoms at 1 yr. The adjusted R² of the model was 25.1%.

CONCLUSION

These findings confirm the high incidence of post-concussion symptoms at 1 yr and identify certain associated features that increase risk. This may allow targeting of certain groups, e.g., return to work or victims of assault.

Prognostic factors in traumatic brain injuries in emergency department

Background

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in young adults. The Extended Glasgow Outcome Score (GOSE) has been introduced to assess the global outcome after brain injuries. Therefore, we aimed to evaluate the prognostic factors associated with GOSE.

Materials and Methods

This was a multicenter cross-sectional study conducted on 144 patients with TBI admitted at trauma emergency centers. The patients' information, including demographic characteristics, duration of hospital stay, mechanical ventilation and on-admission laboratory measurements, and on-admission vital signs, were evaluated. The patients' TBI-related symptoms and brain computed tomography (CT) scan findings were recorded.

Results

GOSE assessments showed an increasing trend by the comparison of on-discharge (7.47 ± 1.30), within a month (7.51 ± 1.30) and within 3 months (7.58 ± 1.21) evaluations (P < 0.001). On-discharge GOSE was positively correlated with Glasgow Coma Scale (GCS)(r = 0.729, P < 0.001), motor GCS (r = 0.812, P < 0.001), Hb (r = 0.165, P = 0.048), and pH (r = 0.165, P = 0.048) and inversely with age (r = -0.261, P = 0.002), hospitalization period (r = -0.678, P < 0.001), pulse rate (r = -0.256, P = 0.002), white blood cell (WBC) (r = -0.222, P = 0.008), and triglyceride (r = -0.218, P = 0.009). In multiple linear regression analysis, the associations were significant only for GCS (B = 0.102, 95% confidence interval [CI]: 0-0.202; P = 0.05), hospitalization stay duration (B = -0.004, 95% CI: -0.005--0.003, P = 0.001), and WBC (B = 0.00001, 95% CI: 0.00000014-0.000025; P = 0.024). Among imaging signs and trauma-related symptoms in univariate analysis, intracranial hemorrhage (ICH), interventricular hemorrhage (IVH) (P = 0.006), subarachnoid hemorrhage (SAH) (P = 0.06; marginally at P < 0.1), subdural hemorrhage (SDH) (P = 0.032), and epidural hemorrhage (EDH) (P = 0.037) was significantly associated with GOSE at discharge in multivariable analysis.

Conclusion

According to the current study findings, GCS, hospitalization stay duration, WBC and among imaging signs and trauma-related symptoms ICH, IVH, SAH, SDH, and EDH are independent significant predictors of GOSE at discharge in TBI patients.

External validation of the Glasgow coma scale-pupils in low- to middle-income country patients with traumatic brain injury: Could “motor score-pupil” have higher prognostic value?

Background:

The objective of this study is to validate the admission Glasgow coma scale (GCS) associated with pupil response (GCS-P) to predict traumatic brain injury (TBI) patient’s outcomes in a low- to middle-income country and to compare its performance with that of a simplified model combining the better motor response of the GCS and the pupilar response (MS-P).

Methods:

This is a prospective cohort of patients with TBI in a tertiary trauma reference center in Brazil. Predictive values of the GCS, GCS-P, and MS-P were evaluated and compared for 14 day and in-hospital mortality outcomes and length of hospital stay (LHS).

Results:

The study enrolled 447 patients. MS-P demonstrated better discriminative ability than GCS to predict mortality (AUC 0.736 × 0.658; P < 0.001) and higher AUC than GCS-P (0.736 × 0.704, respectively; P = 0.073). For hospital mortality, MS-P demonstrated better discrimination than GCS (AUC, 0.750 × 0.682; P < 0.001) and higher AUC than GCS-P (0.750 × 0.714; P = 0.027). Both scores were good predictors of LHS (r2 = 0.084 [GCS-P] × 0.079 [GCS] × 0.072 [MS-P]).

Conclusion:

The predictive value of the GCS, GCS-P, and MS-P scales was demonstrated, thus contributing to its external validation in low- to middle-income country.