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Conradsen I, Bang-Hansen VE, Sørensen AN, Rytter HM. Return to work in persons with persistent postconcussion symptoms: a survey study examining the perspectives of employees and managers. Brain Inj 2024; 38:908-917. [PMID: 38828860 DOI: 10.1080/02699052.2024.2361620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 04/25/2024] [Accepted: 05/27/2024] [Indexed: 06/05/2024]
Abstract
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.
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Affiliation(s)
- Irene Conradsen
- The Danish Concussion Center, Center for Rehabilitation of Brain Injury, Copenhagen, Denmark
| | | | - Alexander N Sørensen
- The Danish Concussion Center, Center for Rehabilitation of Brain Injury, Copenhagen, Denmark
| | - Hana Malá Rytter
- The Danish Concussion Center, Center for Rehabilitation of Brain Injury, Copenhagen, Denmark
- Department of Psychology, University of Copenhagen, Copenhagen, Denmark
- Department of Neurology, University Hospital Bispebjerg - Frederiksberg, Copenhagen, Denmark
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2
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Tate DF, Wade BSC, Velez CS, Bigler ED, Davenport ND, Dennis EL, Esopenko C, Hinds SR, Kean J, Kennedy E, Kenney K, Mayer AR, Newsome MR, Philippi CL, Pugh MJ, Scheibel RS, Taylor BA, Troyanskaya M, Werner JK, York GE, Walker W, Wilde EA. Persistent MRI Findings Unique to Blast and Repetitive Mild TBI: Analysis of the CENC/LIMBIC Cohort Injury Characteristics. Mil Med 2024; 189:e1938-e1946. [PMID: 38401164 PMCID: PMC11363162 DOI: 10.1093/milmed/usae031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 08/04/2023] [Accepted: 02/02/2024] [Indexed: 02/26/2024] Open
Abstract
INTRODUCTION MRI represents one of the clinical tools at the forefront of research efforts aimed at identifying diagnostic and prognostic biomarkers following traumatic brain injury (TBI). Both volumetric and diffusion MRI findings in mild TBI (mTBI) are mixed, making the findings difficult to interpret. As such, additional research is needed to continue to elucidate the relationship between the clinical features of mTBI and quantitative MRI measurements. MATERIAL AND METHODS Volumetric and diffusion imaging data in a sample of 976 veterans and service members from the Chronic Effects of Neurotrauma Consortium and now the Long-Term Impact of Military-Relevant Brain Injury Consortium observational study of the late effects of mTBI in combat with and without a history of mTBI were examined. A series of regression models with link functions appropriate for the model outcome were used to evaluate the relationships among imaging measures and clinical features of mTBI. Each model included acquisition site, participant sex, and age as covariates. Separate regression models were fit for each region of interest where said region was a predictor. RESULTS After controlling for multiple comparisons, no significant main effect was noted for comparisons between veterans and service members with and without a history of mTBI. However, blast-related mTBI were associated with volumetric reductions of several subregions of the corpus callosum compared to non-blast-related mTBI. Several volumetric (i.e., hippocampal subfields, etc.) and diffusion (i.e., corona radiata, superior longitudinal fasciculus, etc.) MRI findings were noted to be associated with an increased number of repetitive mTBIs versus. CONCLUSIONS In deployment-related mTBI, significant findings in this cohort were only observed when considering mTBI sub-groups (blast mechanism and total number/dose). Simply comparing healthy controls and those with a positive mTBI history is likely an oversimplification that may lead to non-significant findings, even in consortium analyses.
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Affiliation(s)
- David F Tate
- Department of Neurology, Traumatic Brain Injury and Concussion Center, University of Utah, Salt Lake City, UT 84132, USA
- George E. Wahlen VA Salt Lake City Healthcare System, Salt Lake City, UT 84148, USA
- Department of Psychology, Brigham Young University, Provo, UT 84604, USA
| | - Benjamin S C Wade
- Department of Neurology, Traumatic Brain Injury and Concussion Center, University of Utah, Salt Lake City, UT 84132, USA
- Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Carmen S Velez
- Department of Neurology, Traumatic Brain Injury and Concussion Center, University of Utah, Salt Lake City, UT 84132, USA
- George E. Wahlen VA Salt Lake City Healthcare System, Salt Lake City, UT 84148, USA
| | - Erin D Bigler
- Department of Neurology, Traumatic Brain Injury and Concussion Center, University of Utah, Salt Lake City, UT 84132, USA
- Department of Psychology, Brigham Young University, Provo, UT 84604, USA
- Departments of Neuroscience, Brigham Young University, Provo, UT 84604, USA
| | - Nicholas D Davenport
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN 55417, USA
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN 55454, USA
| | - Emily L Dennis
- Department of Neurology, Traumatic Brain Injury and Concussion Center, University of Utah, Salt Lake City, UT 84132, USA
- George E. Wahlen VA Salt Lake City Healthcare System, Salt Lake City, UT 84148, USA
| | - Carrie Esopenko
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Sidney R Hinds
- Department of Neurology, Uniformed Services University, Bethesda, MD 20814, USA
| | - Jacob Kean
- George E. Wahlen VA Salt Lake City Healthcare System, Salt Lake City, UT 84148, USA
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT 84108, USA
| | - Eamonn Kennedy
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT 84108, USA
| | - Kimbra Kenney
- Department of Neurology, Uniformed Services University, Bethesda, MD 20814, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Andrew R Mayer
- The Mind Research Network, University of New Mexico Health Science Center, Albuquerque, NM 87106, USA
| | - Mary R Newsome
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX 77030, USA
- H. Ben Taub Department of Physical Medicine & Rehabilitation, Baylor College of Medicine, Houston, TX 77030, USA
| | - Carissa L Philippi
- Department of Psychological Sciences, University of Missouri-St. Louis, St. Louis, MO 63121, St. Louis
| | - Mary J Pugh
- George E. Wahlen VA Salt Lake City Healthcare System, Salt Lake City, UT 84148, USA
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT 84108, USA
| | - Randall S Scheibel
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX 77030, USA
- H. Ben Taub Department of Physical Medicine & Rehabilitation, Baylor College of Medicine, Houston, TX 77030, USA
| | - Brian A Taylor
- Department of Imaging Physics, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA
| | - Maya Troyanskaya
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX 77030, USA
- H. Ben Taub Department of Physical Medicine & Rehabilitation, Baylor College of Medicine, Houston, TX 77030, USA
| | - John K Werner
- Department of Neurology, Uniformed Services University, Bethesda, MD 20814, USA
| | - Gerald E York
- Imaging Associates of Alaska, Anchorage, AK 99508, USA
| | - William Walker
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Elisabeth A Wilde
- Department of Neurology, Traumatic Brain Injury and Concussion Center, University of Utah, Salt Lake City, UT 84132, USA
- George E. Wahlen VA Salt Lake City Healthcare System, Salt Lake City, UT 84148, USA
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX 77030, USA
- H. Ben Taub Department of Physical Medicine & Rehabilitation, Baylor College of Medicine, Houston, TX 77030, USA
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Mills SJ, Halstead H, Howie J, Hutchins S, Forte L, Unsworth D, Walters T, Jelbart M, Dodd B, van den Berg M, Killington M. Team-based rehabilitation after mild traumatic brain injury - description of the clinical pathway. Brain Inj 2024; 38:807-817. [PMID: 38695320 DOI: 10.1080/02699052.2024.2347570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 04/20/2024] [Indexed: 07/12/2024]
Abstract
PURPOSE Describe clinical practice, inter-disciplinary clinical pathway and core principles of care within a mild traumatic brain injury (mTBI) rehabilitation team. METHODS An observational study examined inter-disciplinary practice, nested within an observational trial investigating team-based mTBI rehabilitation. Data were collected to describe clinical service over 12 months. Activity data quantified clinical sessions per participant, mode of service delivery and content of sessions using custom-designed codes. The clinical team gathered narrative data to confirm the inter-disciplinary clinical pathway and individual discipline practice. RESULTS 168 participants entered the rehabilitation program during the 12 months. A single Allied Health Screening Assessment identified patient priorities. Occupational Therapy (OT) and Physiotherapy (PT) provided the majority of clinical sessions; the team also comprised Social Work, Rehabilitation Medicine, Speech Pathology and Clinical Psychology. Telehealth was the most common service delivery mode (54%). Median session numbers per participant ranged 1-4 for all disciplines; mean/maximum occasions of service were highest for PT (6.9/44) and OT (6.8/39). CONCLUSION A small proportion of participants received much higher number of sessions, consistent with intractable issues after mTBI. High attendance rates indicate the predominantly telehealth-delivered model was feasible. The clinical approach included early prioritizing of discipline input and follow-up after discharge.
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Affiliation(s)
- Simon J Mills
- South Australian Brain Injury Rehabilitation Service, Repat Health Precinct, Adelaide, Australia
| | - Hannah Halstead
- South Australian Brain Injury Rehabilitation Service, Repat Health Precinct, Adelaide, Australia
| | - Joanne Howie
- South Australian Brain Injury Rehabilitation Service, Repat Health Precinct, Adelaide, Australia
| | - Selena Hutchins
- South Australian Brain Injury Rehabilitation Service, Repat Health Precinct, Adelaide, Australia
| | - Leah Forte
- South Australian Brain Injury Rehabilitation Service, Repat Health Precinct, Adelaide, Australia
| | - David Unsworth
- South Australian Brain Injury Rehabilitation Service, Repat Health Precinct, Adelaide, Australia
| | - Terri Walters
- South Australian Brain Injury Rehabilitation Service, Repat Health Precinct, Adelaide, Australia
| | - Miranda Jelbart
- South Australian Brain Injury Rehabilitation Service, Repat Health Precinct, Adelaide, Australia
| | - Beverley Dodd
- South Australian Brain Injury Rehabilitation Service, Repat Health Precinct, Adelaide, Australia
| | - Maayken van den Berg
- College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Maggie Killington
- South Australian Brain Injury Rehabilitation Service, Repat Health Precinct, Adelaide, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
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Papini MG, Avila AN, Fitzgerald M, Hellewell SC. Evidence for Altered White Matter Organization After Mild Traumatic Brain Injury: A Scoping Review on the Use of Diffusion Magnetic Resonance Imaging and Blood-Based Biomarkers to Investigate Acute Pathology and Relationship to Persistent Post-Concussion Symptoms. J Neurotrauma 2024. [PMID: 39096132 DOI: 10.1089/neu.2024.0039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024] Open
Abstract
Mild traumatic brain injury (mTBI) is the most common form of traumatic brain injury. Post-concussive symptoms typically resolve after a few weeks although up to 20% of people experience these symptoms for >3 months, termed persistent post-concussive symptoms (PPCS). Subtle white matter (WM) microstructural damage is thought to underlie neurological and cognitive deficits experienced post-mTBI. Evidence suggests that diffusion magnetic resonance imaging (dMRI) and blood-based biomarkers could be used as surrogate markers of WM organization. We conducted a scoping review according to PRISMA-ScR guidelines, aiming to collate evidence for the use of dMRI and/or blood-based biomarkers of WM organization, in mTBI and PPCS, and document relationships between WM biomarkers and symptoms. We focused specifically on biomarkers of axonal or myelin integrity post-mTBI. Biomarkers excluded from this review therefore included the following: astroglial, perivascular, endothelial, and inflammatory markers. A literature search performed across four databases, EMBASE, Scopus, Google Scholar, and ProQuest, identified 100 records: 68 analyzed dMRI, 28 assessed blood-based biomarkers, and 4 used both. Blood biomarker studies commonly assessed axonal cytoskeleton proteins (i.e., tau); dMRI studies assessed measures of WM organization (i.e., fractional anisotropy). Significant biomarker alterations were frequently associated with heightened symptom burden and prolonged recovery time post-injury. These data suggest that dMRI and blood-based biomarkers may be useful proxies of WM organization, although few studies assessed these complementary measures in parallel, and the relationship between modalities remains unclear. Further studies are warranted to assess the benefit of a combined biomarker approach in evaluating alterations to WM organization after mTBI.
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Affiliation(s)
- Melissa G Papini
- Curtin Medical School, Faculty of Health Sciences, Curtin University, Perth, Australia
- Curtin Health Innovation Research Institute, Curtin University, Perth, Australia
- Perron Institute for Neurological and Translational Science, Perth, Australia
| | - André N Avila
- Curtin Medical School, Faculty of Health Sciences, Curtin University, Perth, Australia
- Curtin Health Innovation Research Institute, Curtin University, Perth, Australia
- Perron Institute for Neurological and Translational Science, Perth, Australia
| | - Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Curtin University, Perth, Australia
- Perron Institute for Neurological and Translational Science, Perth, Australia
| | - Sarah C Hellewell
- Curtin Health Innovation Research Institute, Curtin University, Perth, Australia
- Perron Institute for Neurological and Translational Science, Perth, Australia
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Lujan A, Lin K. Rehabilitation of Persistent Symptoms After Concussion. Phys Med Rehabil Clin N Am 2024; 35:535-546. [PMID: 38945649 DOI: 10.1016/j.pmr.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
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.
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Affiliation(s)
- Ashley Lujan
- Department of Rehabilitation Medicine, South Texas VAHCS, 7400 Merton Minter, San Antonio, TX 78229, USA.
| | - Katherine Lin
- Department of Physical Medicine and Rehabilitation, Palo Alto VAMC, 3801 Miranda Avenue, Building 500, Palo Alto, CA 94304, USA
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Backus BE, Moustafa F, Skogen K, Sapin V, Rane N, Moya-Torrecilla F, Biberthaler P, Tenovuo O. Consensus paper on the assessment of adult patients with traumatic brain injury with Glasgow Coma Scale 13-15 at the emergency department: A multidisciplinary overview. Eur J Emerg Med 2024; 31:240-249. [PMID: 38744295 DOI: 10.1097/mej.0000000000001140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
Traumatic brain injury (TBI) is a common reason for presenting to emergency departments (EDs). The assessment of these patients is frequently hampered by various confounders, and diagnostics is still often based on nonspecific clinical signs. Throughout Europe, there is wide variation in clinical practices, including the follow-up of those discharged from the ED. The objective is to present a practical recommendation for the assessment of adult patients with an acute TBI, focusing on milder cases not requiring in-hospital care. The aim is to advise on and harmonize practices for European settings. A multiprofessional expert panel, giving consensus recommendations based on recent scientific literature and clinical practices, is employed. The focus is on patients with a preserved consciousness (Glasgow Coma Scale 13-15) not requiring in-hospital care after ED assessment. The main results of this paper contain practical, clinically usable recommendations for acute clinical assessment, decision-making on acute head computerized tomography (CT), use of biomarkers, discharge options, and needs for follow-up, as well as a discussion of the main features and risk factors for prolonged recovery. In conclusion, this consensus paper provides a practical stepwise approach for the clinical assessment of patients with an acute TBI at the ED. Recommendations are given for the performance of acute head CT, use of brain biomarkers and disposition after ED care including careful patient information and organization of follow-up for those discharged.
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Affiliation(s)
- Barbra E Backus
- Emergency Department, Franciscus Gasthuis and Vlietland, Rotterdam
- Emergency Department, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Farès Moustafa
- Emergency Department, University Hospital Clermont Auvergne, Clermont-Ferrand, France
| | - Karoline Skogen
- Department of Radiology and Nuclear Medicine, Oslo University Hospitals, Oslo, Norway
| | - Vincent Sapin
- Biochemistry and Molecular Genetics Department, University Hospital Clermont Auvergne, Clermont-Ferrand, France
| | - Neil Rane
- Department of Neuroradiology, St Marys Hospital Major Trauma Centre, Imperial College London NHS Trust
| | - Francisco Moya-Torrecilla
- Physical Therapy Department, School of Health Sciences, University of Malaga, Spain
- International Medical Services, Vithas Xanit International Hospital, Malaga, Spain
| | - Peter Biberthaler
- Department of Trauma Surgery, Klinikum rechts der Isar Technische Universität, Munich, Germany
| | - Olli Tenovuo
- Department of Clinical Medicine, University of Turku, Turku, Finland
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7
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Bertò G, Rooks LT, Broglio SP, McAllister TA, McCrea MA, Pasquina PF, Giza C, Brooks A, Mihalik J, Guskiewicz K, Goldman J, Duma S, Rowson S, Port NL, Pestilli F. Diffusion tensor analysis of white matter tracts is prognostic of persisting post-concussion symptoms in collegiate athletes. Neuroimage Clin 2024; 43:103646. [PMID: 39106542 PMCID: PMC11347060 DOI: 10.1016/j.nicl.2024.103646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 06/15/2024] [Accepted: 07/19/2024] [Indexed: 08/09/2024]
Abstract
BACKGROUND AND OBJECTIVES After a concussion diagnosis, the most important issue for patients and loved ones is how long it will take them to recover. The main objective of this study is to develop a prognostic model of concussion recovery. This model would benefit many patients worldwide, allowing for early treatment intervention. METHODS The Concussion Assessment, Research and Education (CARE) consortium study enrolled collegiate athletes from 30 sites (NCAA athletic departments and US Department of Defense service academies), 4 of which participated in the Advanced Research Core, which included diffusion-weighted MRI (dMRI) data collection. We analyzed the dMRI data of 51 injuries of concussed athletes scanned within 48 h of injury. All athletes were cleared to return-to-play by the local medical staff following a standardized, graduated protocol. The primary outcome measure is days to clearance of unrestricted return-to-play. Injuries were divided into early (return-to-play < 28 days) and late (return-to-play >= 28 days) recovery based on the return-to-play clinical records. The late recovery group meets the standard definition of Persisting Post-Concussion Symptoms (PPCS). Data were processed using automated, state-of-the-art, rigorous methods for reproducible data processing using brainlife.io. All processed data derivatives are made available at https://brainlife.io/project/63b2ecb0daffe2c2407ee3c5/dataset. The microstructural properties of 47 major white matter tracts, 5 callosal, 15 subcortical, and 148 cortical structures were mapped. Fractional Anisotropy (FA) and Mean Diffusivity (MD) were estimated for each tract and structure. Correlation analysis and Receiver Operator Characteristic (ROC) analysis were then performed to assess the association between the microstructural properties and return-to-play. Finally, a Logistic Regression binary classifier (LR-BC) was used to classify the injuries between the two recovery groups. RESULTS The mean FA across all white matter volume was negatively correlated with return-to-play (r = -0.38, p = 0.00001). No significant association between mean MD and return-to-play was found, neither for FA nor MD for any other structure. The mean FA of 47 white matter tracts was negatively correlated with return-to-play (rμ = -0.27; rσ = 0.08; rmin = -0.1; rmax = -0.43). Across all tracts, a large mean ROC Area Under the Curve (AUCFA) of 0.71 ± 0.09 SD was found. The top classification performance of the LR-BC was AUC = 0.90 obtained using the 16 statistically significant white matter tracts. DISCUSSION Utilizing a free, open-source, and automated cloud-based neuroimaging pipeline and app (https://brainlife.io/docs/tutorial/using-clairvoy/), a prognostic model has been developed, which predicts athletes at risk for slow recovery (PPCS) with an AUC=0.90, balanced accuracy = 0.89, sensitivity = 1.0, and specificity = 0.79. The small number of participants in this study (51 injuries) is a significant limitation and supports the need for future large concussion dMRI studies and focused on recovery.
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Affiliation(s)
- Giulia Bertò
- Department of Psychology and Department of Neuroscience, Center for Perceptual Systems, Center for Learning and Memory, The University of Texas at Austin, Austin, TX, USA
| | - Lauren T Rooks
- Indiana University School of Optometry and Program in Neuroscience, Indiana University, Bloomington IN, USA
| | - Steven P Broglio
- Michigan Concussion Center, University of Michigan, Ann Arbor, MI, USA
| | | | - Michael A McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Paul F Pasquina
- Department of Physical Medicine and Rehabilitation at the Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Christopher Giza
- Pediatric Neurology, University of California, Los Angeles, CA, USA
| | - Alison Brooks
- Department of Orthopaedics and Rehabilitation, University of Wisconsin Madison, Madison WI, USA
| | - Jason Mihalik
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kevin Guskiewicz
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Josh Goldman
- Family Medicine & Sports Medicine, UCLA Medical School, Los Angeles, CA, USA
| | - Stefan Duma
- Departmentl of Biomedical Engineering & Mechanics, Virginia Tech, Blacksburg, VA, USA
| | - Steven Rowson
- Departmentl of Biomedical Engineering & Mechanics, Virginia Tech, Blacksburg, VA, USA
| | - Nicholas L Port
- Indiana University School of Optometry and Program in Neuroscience, Indiana University, Bloomington IN, USA.
| | - Franco Pestilli
- Department of Psychology and Department of Neuroscience, Center for Perceptual Systems, Center for Learning and Memory, The University of Texas at Austin, Austin, TX, USA.
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8
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Tang SJ, Holle J, Dadario NB, Ryan M, Lesslar O, Teo C, Sughrue M, Yeung J. Personalized, parcel-guided non-invasive transcranial magnetic stimulation for the treatment of post-concussive syndrome: safety and proof of concept. Brain Inj 2024:1-11. [PMID: 38965876 DOI: 10.1080/02699052.2024.2371975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 06/15/2024] [Indexed: 07/06/2024]
Abstract
OBJECTIVE To determine the safety and proof of concept of a parcel-guided, repetitive Transcranial Magnetic Stimulation (rTMS) in patients who develop a heterogeneous array of symptoms, known collectively as post-concussive syndrome (PCS), following traumatic brain injury (TBI). METHODS We performed a retrospective review of off-label, individualized, parcel-guided rTMS in 19 patients from December 2020 to May 2023. Patients had at least one instance of mild, moderate, or severe TBI and developed symptoms not present prior to injury. rTMS targets were identified based on machine learning connectomic software using functional connectivity anomaly matrices compared to healthy controls. EuroQol (EQ-5D), as a measurement of quality of life, and additional questionnaires dependent on individual's symptoms were submitted prior to, after, and during follow-up from rTMS. RESULTS Nineteen patients showed improvement in EQ-5D and Rivermead Post Concussion Symptoms Questionnaires - 3 after treatment and follow-up. For nine patients who developed depression, five (55%) attained response and remission based on the Beck Depression Inventory after treatment. Eight of ten patients with anxiety had a clinically significant reduction in Generalized Anxiety Disorder-7 scores during follow-up. CONCLUSION Parcel-guided rTMS is safe and may be effective in reducing PCS symptoms following TBI and should incite further controlled studies.
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Affiliation(s)
- Si Jie Tang
- School of Medicine, University of California Davis Medical Center, Sacramento, California, USA
| | | | - Nicholas B Dadario
- Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, USA
| | | | | | | | | | - Jacky Yeung
- Cingulum Health, Sydney, Australia
- Department of Neurosurgery, Yale University School of Medicine institution, New Haven, Connecticut, USA
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9
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Kingsford O, Yehya M, Zieman G, Knievel KL. Can Long-Term Outcomes of Posttraumatic Headache be Predicted? Curr Pain Headache Rep 2024; 28:535-545. [PMID: 38713368 DOI: 10.1007/s11916-024-01254-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2024] [Indexed: 05/08/2024]
Abstract
PURPOSE OF REVIEW Headache is one of the most common symptoms of traumatic brain injury, and it is more common in patients with mild, rather than moderate or severe, traumatic brain injury. Posttraumatic headache can be the most persistent symptom of traumatic brain injury. In this article, we review the current understanding of posttraumatic headache, summarize the current knowledge of its pathophysiology and treatment, and review the research regarding predictors of long-term outcomes. RECENT FINDINGS To date, posttraumatic headache has been treated based on the semiology of the primary headache disorder that it most resembles, but the pathophysiology is likely to be different, and the long-term prognosis differs as well. No models exist to predict long-term outcomes, and few studies have highlighted risk factors for the development of acute and persistent posttraumatic headaches. Further research is needed to elucidate the pathophysiology and identify specific treatments for posttraumatic headache to be able to predict long-term outcomes. In addition, the effect of managing comorbid traumatic brain injury symptoms on posttraumatic headache management should be further studied. Posttraumatic headache can be a persistent symptom of traumatic brain injury, especially mild traumatic brain injury. It has traditionally been treated based on the semiology of the primary headache disorder it most closely resembles, but further research is needed to elucidate the pathophysiology of posttraumatic headache and determine risk factors to better predict long-term outcomes.
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Affiliation(s)
- Olivia Kingsford
- Department of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W Thomas Rd, Phoenix, AZ, 85013, USA
| | - Mustafa Yehya
- Department of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W Thomas Rd, Phoenix, AZ, 85013, USA
| | - Glynnis Zieman
- Department of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W Thomas Rd, Phoenix, AZ, 85013, USA
| | - Kerry L Knievel
- Department of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W Thomas Rd, Phoenix, AZ, 85013, USA.
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10
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Popovich MJ, Wright BS, Bretzin AC, Roberts MT, Alsalaheen B, Almeida AA, Lorincz MT, Eckner JT. Headache Characteristics of Pediatric Sport-Related Concussion. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:813. [PMID: 39063391 PMCID: PMC11276358 DOI: 10.3390/ijerph21070813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 06/12/2024] [Accepted: 06/18/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND Headache is among the most common symptoms following concussion, yet headache after concussion (HAC) remains poorly characterized. This study describes headache characteristics over the first four weeks following pediatric sport-related concussion. METHODS This is a retrospective case series of 87 athletes (mean: 14.9 years; range: 8.4-18.8 years; 38% female) treated in a specialty sports concussion clinic within 28 days of injury. Primary outcomes of headache consistency, frequency, duration, and associated migrainous symptoms were assessed at immediate (0 to 48 h) and weekly time points over the first 28 days post-injury. Generalized mixed linear models compared headache characteristics across time points. Secondary analyses compared each outcome by as-needed analgesic use. RESULTS During the immediate post-injury period, headache was more often constant (p = 0.002) and associated with migrainous symptoms (p < 0.001). By the third week post-injury, episodic headache was more prevalent (p < 0.001). Most patients (54%) transitioned from constant, migrainous headache to episodic, non-migrainous headache. This finding was uninfluenced by as-needed analgesic medication use. CONCLUSIONS These findings document the trajectory of HAC. Future studies should assess relationships between initial headache characteristics and recovery.
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Affiliation(s)
- Michael J. Popovich
- Department of Neurology, University of Michigan, Ann Arbor, MI 48109, USA; (M.T.R.); (A.A.A.); (M.T.L.)
| | - Brandon S. Wright
- Department of Kinesiology, University of Michigan, Ann Abror, MI 48109, USA;
| | - Abigail C. Bretzin
- Injury Prevention Center, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI 48109, USA;
| | - Mark T. Roberts
- Department of Neurology, University of Michigan, Ann Arbor, MI 48109, USA; (M.T.R.); (A.A.A.); (M.T.L.)
| | - Bara Alsalaheen
- Department of Neurology, University of Michigan, Ann Arbor, MI 48109, USA; (M.T.R.); (A.A.A.); (M.T.L.)
| | - Andrea A. Almeida
- Department of Neurology, University of Michigan, Ann Arbor, MI 48109, USA; (M.T.R.); (A.A.A.); (M.T.L.)
| | - Matthew T. Lorincz
- Department of Neurology, University of Michigan, Ann Arbor, MI 48109, USA; (M.T.R.); (A.A.A.); (M.T.L.)
| | - James T. Eckner
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI 48109, USA;
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11
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Levy AM, Saling MM, Anderson JFI. Psychological distress and gender predict cognitive complaint after adult civilian mild traumatic brain injury in pre-morbidly healthy adults. Neuropsychol Rehabil 2024; 34:721-741. [PMID: 37493086 DOI: 10.1080/09602011.2023.2236348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 06/24/2023] [Indexed: 07/27/2023]
Abstract
Subjective cognitive symptoms are common after mild traumatic brain injury (mTBI), and are associated with important outcome factors including return to work. This study examined self-reported cognitive symptoms in mTBI and trauma controls (TCs), and explored psychological distress and gender as predictors of these symptoms. Pre-morbidly healthy adults with mTBI (n = 68) and general trauma (n = 40) were prospectively recruited from inpatient hospital wards and assessed 6-10 weeks post-injury. Primary measures included self-reported cognitive symptoms, post-concussion symptoms, and psychological distress. Groups were matched on all background variables, including objective cognitive performance. Within this context, subjective cognitive symptoms were significantly elevated after mTBI relative to TCs (t = 3.396, p = .001). In contrast, there was no difference in post-concussion symptoms between groups (t = 1.275, p = .206). Psychological distress (β = .536, p < .001) and gender (β = .253, p = .012) predicted subjective cognitive symptoms in mTBI, with females and those with higher distress reporting greater symptoms. Unlike general post-concussion symptoms, subjective cognitive symptoms were elevated after mTBI relative to TCs, suggesting that mTBI-specific factors underly this elevation. Females and individuals with high psychological distress are important subgroups to consider for potential intervention following mTBI.
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Affiliation(s)
- Arielle M Levy
- Melbourne School of Psychological Sciences, The University of Melbourne, Melbourne, Australia
| | - Michael M Saling
- Melbourne School of Psychological Sciences, The University of Melbourne, Melbourne, Australia
| | - Jacqueline F I Anderson
- Melbourne School of Psychological Sciences, The University of Melbourne, Melbourne, Australia
- Psychology Department, The Alfred Hospital, Melbourne, Australia
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12
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King JA, Nelson LD, Cheever K, Brett B, Gliedt J, Szabo A, Dong H, Huber DL, Broglio SP, McAllister TW, McCrea M, Pasquina P, Feigenbaum LA, Hoy A, Mihalik JP, Duma SM, Buckley T, Kelly LA, Miles C, Goldman JT, Benjamin HJ, Master CL, Ortega J, Kontos A, Clugston JR, Cameron KL, Kaminski TW, Chrisman SP, Eckner JT, Port N, McGinty G. The Prevalence and Influence of New or Worsened Neck Pain After a Sport-Related Concussion in Collegiate Athletes: A Study From the CARE Consortium. Am J Sports Med 2024; 52:1845-1854. [PMID: 38742422 DOI: 10.1177/03635465241247212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
BACKGROUND Neck pain in a concussion population is an emerging area of study that has been shown to have a negative influence on recovery. This effect has not yet been studied in collegiate athletes. HYPOTHESIS New or worsened neck pain is common after a concussion (>30%), negatively influences recovery, and is associated with patient sex and level of contact in sport. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Varsity-level athletes from 29 National Collegiate Athletic Association member institutions as well as nonvarsity sport athletes at military service academies were eligible for enrollment. Participants completed a preseason baseline assessment and follow-up assessments at 6 and 24 to 48 hours after a concussion, when they were symptom-free, and when they returned to unrestricted play. Data collection occurred between January 2014 and September 2018. RESULTS A total of 2163 injuries were studied. New or worsened neck pain was reported with 47.0% of injuries. New or worsened neck pain was associated with patient sex (higher in female athletes), an altered mental status after the injury, the mechanism of injury, and what the athlete collided with. The presence of new/worsened neck pain was associated with delayed recovery. Those with new or worsened neck pain had 11.1 days of symptoms versus 8.8 days in those without (P < .001). They were also less likely to have a resolution of self-reported symptoms in ≤7 days (P < .001). However, the mean duration of the return-to-play protocol was not significantly different for those with new or worsened neck pain (7.5 ± 7.7 days) than those without (7.4 ± 8.3 days) (P = .592). CONCLUSION This novel study shows that neck pain was common in collegiate athletes sustaining a concussion, was influenced by many factors, and negatively affected recovery.
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Affiliation(s)
- Jeffrey A King
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Lindsay
| | - Lindsay D Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Kelly Cheever
- Applied Biomechanics Research Laboratory, Department of Kinesiology, College for Health, Community and Policy, The University of Texas at San Antonio, San Antonio, Texas, USA
| | - Benjamin Brett
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jordan Gliedt
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Aniko Szabo
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Huaying Dong
- Division of Biostatistics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel L Huber
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Steven P Broglio
- University of Michigan Concussion Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Thomas W McAllister
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Michael McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Paul Pasquina
- Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Luis A Feigenbaum
- Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - April Hoy
- Department of Athletics, School of Behavioral and Applied Sciences, Azusa Pacific University, Azusa, California, USA
| | - Jason P Mihalik
- Department of Exercise and Sport Science, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Stefan M Duma
- Institute for Critical Technology and Applied Science, Virginia Polytechnic Institute and State University, Blacksburg, Virginia, USA
| | - Thomas Buckley
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware, USA
| | - Louise A Kelly
- Department of Exercise Science, California Lutheran University, Thousand Oaks, California, USA
| | - Chris Miles
- Department of Family and Community Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Joshua T Goldman
- Departments of Family Medicine and Orthopaedic Surgery, University of California, Los Angeles, Los Angeles, California, USA
| | - Holly J Benjamin
- Departments of Orthopaedic Surgery and Rehabilitation Medicine and Pediatrics, University of Chicago, Chicago, Illinois, USA
| | - Christina L Master
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Justus Ortega
- School of Applied Health, California State Polytechnic University, Humboldt, Arcata, California, USA
| | - Anthony Kontos
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - James R Clugston
- Department of Community Health and Family Medicine, University of Florida, Gainesville, Florida, USA
| | - Kenneth L Cameron
- Orthopaedic and Sports Medicine Research, United States Military Academy, West Point, New York, USA
| | - Thomas W Kaminski
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware, USA
| | - Sara P Chrisman
- Division of Adolescent Medicine, Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - James T Eckner
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan, USA
| | - Nicholas Port
- School of Optometry, Indiana University Bloomington, Bloomington, Indiana, USA
| | - Gerald McGinty
- Department of Athletics, United States Air Force Academy, Air Force Academy, Colorado, USA
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Clarke GJB, Skandsen T, Zetterberg H, Follestad T, Einarsen CE, Vik A, Mollnes TE, Pischke SE, Blennow K, Håberg AK. Longitudinal Associations Between Persistent Post-Concussion Symptoms and Blood Biomarkers of Inflammation and CNS-Injury After Mild Traumatic Brain Injury. J Neurotrauma 2024; 41:862-878. [PMID: 38117157 DOI: 10.1089/neu.2023.0419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023] Open
Abstract
The aim of our study was to investigate the biological underpinnings of persistent post-concussion symptoms (PPCS) at 3 months following mild traumatic brain injury (mTBI). Patients (n = 192, age 16-60 years) with mTBI, defined as Glasgow Coma Scale (GCS) score between 13 and 15, loss of consciousness (LOC) <30 min, and post-traumatic amnesia (PTA) <24 h were included. Blood samples were collected at admission (within 72 h), 2 weeks, and 3 months. Concentrations of blood biomarkers associated with central nervous system (CNS) damage (glial fibrillary acidic protein [GFAP], neurofilament light [NFL], and tau) and inflammation (interferon gamma [IFNγ], interleukin [IL]-8, eotaxin, macrophage inflammatory protein-1-beta [MIP]-1β, monocyte chemoattractant protein [MCP]-1, interferon-gamma-inducible protein [IP]-10, IL-17A, IL-9, tumor necrosis factor [TNF], basic fibroblast growth factor [FGF]-basic platelet-derived growth factor [PDGF], and IL-1 receptor antagonist [IL-1ra]) were obtained. Demographic and injury-related factors investigated were age, sex, GCS score, LOC, PTA duration, traumatic intracranial finding on magnetic resonance imaging (MRI; within 72 h), and extracranial injuries. Delta values, that is, time-point differences in biomarker concentrations between 2 weeks minus admission and 3 months minus admission, were also calculated. PPCS was assessed with the British Columbia Post-Concussion Symptom Inventory (BC-PSI). In single variable analyses, longer PTA duration and a higher proportion of intracranial findings on MRI were found in the PPCS group, but no single biomarker differentiated those with PPCS from those without. In multi-variable models, female sex, longer PTA duration, MRI findings, and lower GCS scores were associated with increased risk of PPCS. Inflammation markers, but not GFAP, NFL, or tau, were associated with PPCS. At admission, higher concentrations of IL-8 and IL-9 and lower concentrations of TNF, IL-17a, and MCP-1 were associated with greater likelihood of PPCS; at 2 weeks, higher IL-8 and lower IFNγ were associated with PPCS; at 3 months, higher PDGF was associated with PPCS. Higher delta values of PDGF, IL-17A, and FGF-basic at 2 weeks compared with admission, MCP-1 at 3 months compared with admission, and TNF at 2 weeks and 3 months compared with admission were associated with greater likelihood of PPCS. Higher IL-9 delta values at both time-point comparisons were negatively associated with PPCS. Discriminability of individual CNS-injury and inflammation biomarkers for PPCS was around chance level, whereas the optimal combination of biomarkers yielded areas under the curve (AUCs) between 0.62 and 0.73. We demonstrate a role of biological factors on PPCS, including both positive and negative effects of inflammation biomarkers that differed based on sampling time-point after mTBI. PPCS was associated more with acute inflammatory processes, rather than ongoing inflammation or CNS-injury biomarkers. However, the modest discriminative ability of the models suggests other factors are more important in the development of PPCS.
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Affiliation(s)
- Gerard Janez Brett Clarke
- Department of Radiology and Nuclear Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Neuromedicine and Movement Sciences, Department of Clinical and Molecular Research, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Toril Skandsen
- Department of Neuromedicine and Movement Sciences, Department of Clinical and Molecular Research, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Rehabilitation, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
- UK Dementia Research Institute at UCL, University College London, London, United Kingdom
- Hong Kong Center for Neurodegenerative Diseases, Clear Water Bay, Hong Kong, China
- Wisconsin Alzheimer's Disease Research Center, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Turid Follestad
- Department of Clinical and Molecular Medicine, Department of Clinical and Molecular Research, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinical Research Unit Central Norway, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Cathrine Elisabeth Einarsen
- Department of Neuromedicine and Movement Sciences, Department of Clinical and Molecular Research, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Rehabilitation, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Anne Vik
- Department of Neuromedicine and Movement Sciences, Department of Clinical and Molecular Research, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Department of Neurosurgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Tom Eirik Mollnes
- Department of Immunology, Department of Anesthesiology and Intensive Care Medicine, Oslo University Hospital and University of Oslo, Oslo, Norway
- Center of Molecular Inflammation Research, Department of Clinical and Molecular Research, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Søren Erik Pischke
- Department of Immunology, Department of Anesthesiology and Intensive Care Medicine, Oslo University Hospital and University of Oslo, Oslo, Norway
- Clinic for Emergencies and Critical Care, Department of Anesthesiology and Intensive Care Medicine, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Asta Kristine Håberg
- Department of Radiology and Nuclear Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Neuromedicine and Movement Sciences, Department of Clinical and Molecular Research, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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14
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Mavroudis I, Balmus IM, Ciobica A, Hogas M. A Narrative Review Of Risk Factors And Predictors For Poor Outcome And Prolonged Recovery After A Mild Traumatic Brain Injury. Int J Neurosci 2024:1-22. [PMID: 38465501 DOI: 10.1080/00207454.2024.2328710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 03/05/2024] [Indexed: 03/12/2024]
Abstract
MATERIAL AND METHODS A comprehensive search of the main scientific databases (PubMed, Web of Science, Embase, and Cochrane Library) was performed using keywords, such as: "prolonged post-concussion syndrome", combined with "risk factors", "predictors", and "outcomes". RESULTS Multiple studies reported more than one risk factor for PPCS development following mTBIs that were generally the results of sports-related concussions and car accidents. The most prevalent risk factor associated with PPCS was the female sex. Social factors/personality traits, anxiety, mental health disorders, or other health conditions from their past medical history, the occurrence of headache/migraines during TBI recovery, somatization, physical activity, and litigation were also reported to contribute to PPCS risk. CONCLUSIONS An exhaustive approach is required to mitigate the risk of PPCS and to ensure optimal recovery after concussive events. However, larger prospective cohort studies evaluating patients that were examined and treated with standardized protocols could be needed to further validate these associations and mandate the highest risk factors for delayed recovery.
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Affiliation(s)
- Ioannis Mavroudis
- Department of Neurology, Leeds Teaching Hospitals, NHS Trust, Leeds, UK
| | - Ioana-Miruna Balmus
- Department of Exact Sciences and Natural Sciences, Institute of Interdisciplinary Research, Alexandru Ioan Cuza University of Iași, 700057 Iași, Romania
- CENEMED Platform for Interdisciplinary Research, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Alin Ciobica
- Department of Biology, Faculty of Biology, Alexandru Ioan Cuza University of Iasi, B dul Carol I, No. 11, 700506 Iasi, Romania
- Academy of Romanian Scientists, Splaiul Independentei nr. 54, Sector 5, 050094 Bucuresti, Romania
- Centre of Biomedical Research, Romanian Academy, B dul Carol I, No. 8, 700506 Iasi, Romania
- Preclinical Department, Apollonia University, Păcurari Street 11, 700511 Iasi, Romania
| | - Mihai Hogas
- Department of Physiology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
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15
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Boucher V, Frenette J, Neveu X, Tardif PA, Mercier É, Chauny JM, Berthelot S, Archambault P, Lee J, Perry JJ, McRae A, Lang E, Moore L, Cameron P, Ouellet MC, de Guise E, Swaine B, Émond M, Le Sage N. Lack of association between four biomarkers and persistent post-concussion symptoms after a mild traumatic brain injury. J Clin Neurosci 2023; 118:34-43. [PMID: 37857062 DOI: 10.1016/j.jocn.2023.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 08/07/2023] [Accepted: 10/10/2023] [Indexed: 10/21/2023]
Abstract
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.
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Affiliation(s)
- Valérie Boucher
- CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Québec, Québec G1J 1Z4, Canada
| | - Jérôme Frenette
- CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Québec, Québec G1J 1Z4, Canada; Faculté de médecine, Université Laval, 1050 Av. de la Médecine, Québec, Québec G1V 0A6, Canada
| | - Xavier Neveu
- CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Québec, Québec G1J 1Z4, Canada
| | - Pier-Alexandre Tardif
- CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Québec, Québec G1J 1Z4, Canada
| | - Éric Mercier
- CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Québec, Québec G1J 1Z4, Canada; Faculté de médecine, Université Laval, 1050 Av. de la Médecine, Québec, Québec G1V 0A6, Canada; VITAM-Centre de recherche en santé durable, 2480 Chem. de la Canardière, Québec, Québec G1J 2G1, Canada
| | - Jean-Marc Chauny
- Faculté de médecine, Université de Montréal, 2900 Edouard Montpetit Blvd, Montréal, Québec H3T 1J4, Canada
| | - Simon Berthelot
- CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Québec, Québec G1J 1Z4, Canada; Faculté de médecine, Université Laval, 1050 Av. de la Médecine, Québec, Québec G1V 0A6, Canada
| | - Patrick Archambault
- Faculté de médecine, Université Laval, 1050 Av. de la Médecine, Québec, Québec G1V 0A6, Canada; VITAM-Centre de recherche en santé durable, 2480 Chem. de la Canardière, Québec, Québec G1J 2G1, Canada; Centre de recherche du CISSS de Chaudière-Appalaches, 143 Rue Wolfe, Lévis, Québec, QC G6V 3Z1, Canada
| | - Jacques Lee
- Sunnybrook Health Science Center, 2075 Bayview Ave, Toronto, Ontario M4N 3M5, Canada; Schwartz-Reisman Emergency Medicine Institute, Mount Sinai Hospital, 600 University Ave, Toronto, Ontario M5G 1X5, Canada
| | - Jeffrey J Perry
- The Ottawa Hospital Research Institute, 501 Smyth Box 511, Ottawa, Ontario K1H 8L6, Canada; Department of Emergency Medicine, University of Ottawa, 75 Laurier Ave E, Ottawa, Ontario K1N 6N5, Canada
| | - Andrew McRae
- Department of Emergency Medicine, University of Calgary, 2500 University Dr NW, Calgary, Alberta T2N 1N4, Canada; Foothills Medical Centre, 1403 29 St NW, Calgary, Alberta T2N 2T9, Canada
| | - Eddy Lang
- Department of Emergency Medicine, University of Calgary, 2500 University Dr NW, Calgary, Alberta T2N 1N4, Canada; Foothills Medical Centre, 1403 29 St NW, Calgary, Alberta T2N 2T9, Canada
| | - Lynne Moore
- CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Québec, Québec G1J 1Z4, Canada; Faculté de médecine, Université Laval, 1050 Av. de la Médecine, Québec, Québec G1V 0A6, Canada
| | - Peter Cameron
- Alfred Emergency and Trauma Centre, Monash University, 55 Commercial Rd, Melbourne, VIC 3004, Australia
| | - Marie-Christine Ouellet
- Faculté de médecine, Université Laval, 1050 Av. de la Médecine, Québec, Québec G1V 0A6, Canada; Centre interdisciplinaire de recherche en réadaptation et intégration sociale (CIRRIS), 525 Bd Wilfrid-Hamel, Québec, Québec G1M 2S8, Canada
| | - Elaine de Guise
- Département de psychologie, Université de Montréal, 2900, boul. Édouard-Montpetit, Montréal, Québec H3T 1J4, Canada; Centre de recherche interdisciplinaire en réadaptation (CRIR) du Montréal métropolitain, 6363, chemin Hudson, Montréal, Québec H3S 1M9, Canada
| | - Bonnie Swaine
- Faculté de médecine, Université de Montréal, 2900 Edouard Montpetit Blvd, Montréal, Québec H3T 1J4, Canada; Centre de recherche interdisciplinaire en réadaptation (CRIR) du Montréal métropolitain, 6363, chemin Hudson, Montréal, Québec H3S 1M9, Canada
| | - Marcel Émond
- CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Québec, Québec G1J 1Z4, Canada; Faculté de médecine, Université Laval, 1050 Av. de la Médecine, Québec, Québec G1V 0A6, Canada; VITAM-Centre de recherche en santé durable, 2480 Chem. de la Canardière, Québec, Québec G1J 2G1, Canada
| | - Natalie Le Sage
- CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Québec, Québec G1J 1Z4, Canada; Faculté de médecine, Université Laval, 1050 Av. de la Médecine, Québec, Québec G1V 0A6, Canada; VITAM-Centre de recherche en santé durable, 2480 Chem. de la Canardière, Québec, Québec G1J 2G1, Canada.
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16
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Chung JS, Jouk A, Licona NP, Terry JH, Harris OA. In her own words: a phenomenological analysis of stories told by female service members and veterans after traumatic brain injury. Disabil Rehabil 2023; 45:4086-4093. [PMID: 36398683 DOI: 10.1080/09638288.2022.2146766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 11/05/2022] [Indexed: 11/19/2022]
Abstract
PURPOSE Given the majority of Service Members and Veterans (SMV) who have sustained a traumatic brain injury (TBI) are male, the female experience with TBI has not been captured in the general understanding of TBI. To improve understanding of the experience of female SMV after TBI utilizing a qualitative phenomenological approach on stories as told by female SMV. MATERIALS AND METHODS Ten female SMV participated in storytelling workshops and created video stories documenting their personal experience with TBI. Workshops were hosted by the VA Palo Alto Health Care System Polytrauma System of Care (VAPAHCS PSC). A grounded thematic analysis was conducted on the video stories. RESULTS Three common content themes emerged from all the stories: (1) negative psychological and emotional impacts of TBI, (2) acceptance and healing process associated with recovery, and (3) military contexts. Negative psychological and emotional impacts included intrapersonal impacts such as negative emotions, suicidal ideation, and dealing with cognitive and physical challenges, and interpersonal impacts in relationships and loss of independence. Notably, all the stories acknowledged an acceptance and healing process, characterized by several subthemes including motivational factors, TBI education, spirituality, and advocacy work. Lastly, each story mentioned military context, highlighting the unique experience within this population. CONCLUSIONS This phenomenological examination adds evidence-based understanding to the experience after TBI among female SMV. Each story uncovered nuanced and multifaceted issues that women experience in their TBI recovery. Our findings provide context to guide future intervention on the care, support, and TBI recovery for the female SMV population.
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Affiliation(s)
- Joyce S Chung
- Polytrauma System of Care, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Alexandra Jouk
- Polytrauma System of Care, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Nytzia P Licona
- Polytrauma System of Care, VA Palo Alto Health Care System, Palo Alto, CA, USA
- University of Illinois Chicago, Palo Alto, CA, USA
| | - Jennifer H Terry
- Polytrauma System of Care, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Odette A Harris
- Polytrauma System of Care, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Stanford University, Stanford, CA, USA
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17
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Lee MY, Son M, Lee HH, Kang MG, Yun SJ, Seo HG, Kim Y, Oh BM. Proteomic discovery of prognostic protein biomarkers for persisting problems after mild traumatic brain injury. Sci Rep 2023; 13:19786. [PMID: 37957236 PMCID: PMC10643618 DOI: 10.1038/s41598-023-45965-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 10/26/2023] [Indexed: 11/15/2023] Open
Abstract
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.
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Affiliation(s)
- Min-Yong Lee
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Rehabilitation Medicine, National Traffic Injury Rehabilitation Hospital, Yangpyeong, Korea
| | - Minsoo Son
- Interdisciplinary Program of Bioengineering, Seoul National University College of Engineering, Seoul, Korea
- Mass Spectrometry Technology Access Center, McDonnell Genome Institute, Washington University School of Medicine in Saint Louis, St. Louis, MO, USA
| | - Hyun Haeng Lee
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Rehabilitation Medicine, Konkuk University School of Medicine and Konkuk University Medical Center, Seoul, Korea
| | - Min-Gu Kang
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul, Korea
| | - Seo Jung Yun
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul, Korea
| | - Han Gil Seo
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Youngsoo Kim
- Interdisciplinary Program of Bioengineering, Seoul National University College of Engineering, Seoul, Korea.
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Korea.
- Department of Biomedical Science, School of Medicine, CHA University, Seongnam-si, Kyeonggi-do, Korea.
| | - Byung-Mo Oh
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul, Korea.
- Department of Rehabilitation Medicine, National Traffic Injury Rehabilitation Hospital, Yangpyeong, Korea.
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul, Korea.
- Institute on Aging, Seoul National University, Seoul, Korea.
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18
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Durfee KJ, Elbin RJ, Trbovich AM, Womble MN, Mucha A, Stephenson K, Holland CL, Dollar CM, Sparto PJ, Collins MW, Kontos AP. A Common Data Element-Based Adjudication Process for mTBI Clinical Profiles: A Targeted Multidomain Clinical Trial Preliminary Study. Mil Med 2023; 188:354-362. [PMID: 37948273 DOI: 10.1093/milmed/usad149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 02/07/2023] [Accepted: 05/01/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION The primary purpose of this study was to examine the prevalence and percent agreement of clinician-identified mild traumatic brain injury (mTBI) clinical profiles and cutoff scores for selected Federal Interagency Traumatic Brain Injury Research common data elements (CDEs). A secondary purpose was to investigate the predictive value of established CDE assessments in determining clinical profiles in adults with mTBI. MATERIALS AND METHODS Seventy-one (23 males; 48 females) participants (M = 29.00, SD = 7.60, range 18-48 years) within 1-5 months (M = 24.20, SD = 25.30, range 8-154 days) of mTBI completed a clinical interview/exam and a multidomain assessment conducted by a licensed clinician with specialized training in concussion, and this information was used to identify mTBI clinical profile(s). A researcher administered CDE assessments to all participants, and scores exceeding CDE cutoffs were used to identify an mTBI clinical profile. The clinician- and CDE-identified clinical profiles were submitted to a multidisciplinary team for adjudication. The prevalence and percent agreement between clinician- and CDE-identified clinical profiles was documented, and a series of logistic regressions with adjusted odds ratios were performed to identify which CDE assessments best predicted clinician-identified mTBI clinical profiles. RESULTS Migraine/headache, vestibular, and anxiety/mood mTBI clinical profiles exhibited the highest prevalence and overall percent agreement among CDE and clinician approaches. Participants exceeding cutoff scores for the Global Severity Index and Headache Impact Test-6 assessments were 3.90 and 8.81 times more likely to have anxiety/mood and migraine/headache profiles, respectively. The Vestibular/Ocular Motor Screening vestibular items and the Pittsburgh Sleep Quality Index total score were predictive of clinician-identified vestibular and sleep profiles, respectively. CONCLUSIONS The CDEs from migraine/headache, vestibular, and anxiety/mood domains, and to a lesser extent the sleep modifier, may be clinically useful for identifying patients with these profiles following mTBI. However, CDEs for cognitive and ocular may have more limited clinical value for identifying mTBI profiles.
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Affiliation(s)
- Kori J Durfee
- Office for Sport Concussion Research, University of Arkansas, Fayetteville, AR 72701, USA
| | - R J Elbin
- Office for Sport Concussion Research, University of Arkansas, Fayetteville, AR 72701, USA
| | - Alicia M Trbovich
- Department of Orthopaedic Surgery, UPMC Sports Medicine Concussion Program, Pittsburgh, PA 15260, USA
| | - Melissa N Womble
- Inova Sports Medicine Concussion Program, Fairfax, VA 22031, USA
| | - Anne Mucha
- UPMC Rehabilitation Institute, Pittsburgh, PA 15203, USA
| | - Katie Stephenson
- College of Osteopathic Medicine, University of New England, Biddeford, ME 04005, USA
| | - Cyndi L Holland
- Department of Orthopaedic Surgery, UPMC Sports Medicine Concussion Program, Pittsburgh, PA 15260, USA
| | | | - Patrick J Sparto
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA 15260, USA
| | - Michael W Collins
- Department of Orthopaedic Surgery, UPMC Sports Medicine Concussion Program, Pittsburgh, PA 15260, USA
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 15260, USA
| | - Anthony P Kontos
- Department of Orthopaedic Surgery, UPMC Sports Medicine Concussion Program, Pittsburgh, PA 15260, USA
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 15260, USA
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19
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Scott OFT, Bubna M, Boyko E, Hunt C, Kristman VL, Gargaro J, Khodadadi M, Chandra T, Kabir US, Kenrick-Rochon S, Cowle S, Burke MJ, Zabjek KF, Dosaj A, Mushtaque A, Baker AJ, Bayley MT, Tartaglia MC. Characterizing the profiles of patients with acute concussion versus prolonged post-concussion symptoms in Ontario. Sci Rep 2023; 13:17955. [PMID: 37863954 PMCID: PMC10589269 DOI: 10.1038/s41598-023-44095-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 10/03/2023] [Indexed: 10/22/2023] Open
Abstract
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.
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Affiliation(s)
- Olivia F T Scott
- Canadian Concussion Centre, University Health Network, Toronto, ON, Canada
| | | | - Emily Boyko
- EPID@Work Research Institute, Lakehead University, Thunder Bay, ON, Canada
| | - Cindy Hunt
- Head Injury Clinic, Department of Trauma and Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Concussion Ontario Network: Neuroinformatics to Enhance Clinical Care and Translation, Toronto, ON, Canada
| | - Vicki L Kristman
- EPID@Work Research Institute, Lakehead University, Thunder Bay, ON, Canada
- Department of Health Sciences, Lakehead University, Thunder Bay, ON, Canada
| | - Judith Gargaro
- Neurotrauma Care Pathways Project, KITE Research Institute, University Health Network, Toronto, ON, Canada
| | - Mozhgan Khodadadi
- Canadian Concussion Centre, University Health Network, Toronto, ON, Canada
| | - Tharshini Chandra
- Hull-Ellis Concussion Clinic, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Umme Saika Kabir
- EPID@Work Research Institute, Lakehead University, Thunder Bay, ON, Canada
- Department of Health Sciences, Lakehead University, Thunder Bay, ON, Canada
| | - Shannon Kenrick-Rochon
- Northern Ontario School of Medicine University, Thunder Bay, ON, Canada
- Health Sciences North Research Institute, Sudbury, ON, Canada
| | | | - Matthew J Burke
- Neuropsychiatry Program, Division of Neurology, Department of Psychiatry, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Karl F Zabjek
- Department of Physical Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- KITE Research Institute, University Health Network, Toronto, ON, Canada
| | - Anil Dosaj
- Head Injury Clinic, Department of Trauma and Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Asma Mushtaque
- Canadian Concussion Centre, University Health Network, Toronto, ON, Canada
| | - Andrew J Baker
- Brain Health and Wellness Research Program, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Faculty of Medicine, Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, University of Toronto, Toronto, ON, Canada
| | - Mark T Bayley
- Hull-Ellis Concussion Clinic, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Division of Physical Medicine and Rehabilitation, Temerty Medicine, University of Toronto, Toronto, ON, Canada
| | - Maria Carmela Tartaglia
- Canadian Concussion Centre, University Health Network, Toronto, ON, Canada.
- Division of Neurology, Toronto Western Hospital, University Health Network, Toronto, ON, Canada.
- Tanz Centre for Research in Neurodegenerative Diseases, University of Toronto, Toronto, ON, Canada.
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20
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Riley M, Mandair R, Belli A, Breeze J, Toman E. Concussion in facial trauma patients: a retrospective analysis of 100 patients from a UK major trauma centre. Br J Oral Maxillofac Surg 2023; 61:553-557. [PMID: 37658027 DOI: 10.1016/j.bjoms.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 07/13/2023] [Accepted: 07/31/2023] [Indexed: 09/03/2023]
Abstract
Concussion is a common and potentially debilitating condition. Research has shown that one-third of patients admitted with facial trauma have concurrent concussion. This study aimed to investigate the burden and management of concussion in patients presenting with acute facial trauma, and to identify potential risk factors within this population. A retrospective observational study was conducted at a UK major trauma centre between 1 January 2019 and 1 February2020. One hundred randomly selected patients who attended the acute clinic responsible for managing facial trauma were identified. No parametric data were included. The Mann-Whitney test was used to detect differences for continuous data, the X2 test for categorical data. Clinical significance was defined as p < 0.05. Forty of 100 patients (40%) had evidence of concussion, of which only 4/40 (10%) had evidence that head injury advice had been given. There was no statistically significant difference between the non-concussed and concussed groups for age (p = 0.145), gender (p = 0.921), mechanism of injury (p = 0.158), or location of facial injury (p = 0.451). Clinical features of concussion were found in 40% of patients suffering from facial injury. Despite this, we found that head injury advice was rarely given. In addition, we identified no risk factors for concussion within this population, highlighting the need to screen all patients who present with facial injury. To improve the identification and management of concussion in these patients, future work should focus on the development of simple screening tools for use in clinic, and the signposting of patients to existing written and online concussion resources.
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Affiliation(s)
- Max Riley
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
| | - Ravina Mandair
- Department of Maxillofacial Surgery, University Hospitals Birmingham, Birmingham, UK.
| | - Antonio Belli
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK; Department of Neurosurgery, University Hospitals Birmingham, Birmingham, UK.
| | - John Breeze
- Department of Maxillofacial Surgery, University Hospitals Birmingham, Birmingham, UK; Royal Centre for Defence Medicine, Birmingham, UK.
| | - Emma Toman
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK; Department of Neurosurgery, University Hospitals Birmingham, Birmingham, UK.
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21
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Aviv I, Shorer M, Fennig S, Aviezer H, Singer-Harel D, Apter A, Pilowsky Peleg T. From acute stress to persistent post-concussion symptoms: The role of parental accommodation and child's coping strategies. Clin Neuropsychol 2023; 37:1389-1409. [PMID: 36416168 DOI: 10.1080/13854046.2022.2145578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 11/04/2022] [Indexed: 11/24/2022]
Abstract
Background: Acute stress following mild Traumatic Brain Injury (mTBI) is highly prevalent and associated with Persistent Post-Concussion symptoms (PPCS). However, the mechanism mediating this relationship is understudied. Objective: To examine whether parental accommodation (i.e. parents' attempts to adjust the environment to the child's difficulties) and child's coping strategies mediate the association between acute stress and PPCS in children following mTBI. Method: Participants were 58 children aged 8-16 who sustained a mTBI and their parents. Children's acute stress (one-week post-injury) and coping strategies (three weeks post-injury), and parental accommodation (three weeks and four months post-injury) were assessed. Outcome measures included PPCS (four months post-injury) and neuropsychological tests of cognitive functioning (attention and memory). A baseline for PPCS was obtained by a retrospective report of pre-injury symptoms immediately after the injury. Results: Children's acute stress and negative coping strategies (escape-oriented coping strategies) and four-months parental accommodation were significantly related to PPCS. Acute stress predicted PPCS and attention and memory performance. Parental accommodation significantly mediated the association between acute stress and PPCS. Conclusions: Stress plays an important role in children's recovery from mTBI and PPCS. Parental accommodation mediates this relationship, and thus, clinical attention to parental reactions during recovery is needed.
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Affiliation(s)
- Irit Aviv
- Department of Psychology, The Hebrew University, Jerusalem, Israel
- Department of Psychological Medicine, Schneider Children's Medical Center of Israel, Petach-Tikva, Israel
| | - Maayan Shorer
- Department of Psychology, Ruppin Academic Center, Emek-Hefer, Israel
| | - Silvana Fennig
- Department of Psychological Medicine, Schneider Children's Medical Center of Israel, Petach-Tikva, Israel
| | - Hillel Aviezer
- Department of Psychology, The Hebrew University, Jerusalem, Israel
| | - Dana Singer-Harel
- Department of Emergency Medicine, Schneider Children's Medical Center of Israel, Petach-Tikva, Israel
| | - Alan Apter
- Department of Psychological Medicine, Schneider Children's Medical Center of Israel, Petach-Tikva, Israel
| | - Tammy Pilowsky Peleg
- Department of Psychology, The Hebrew University, Jerusalem, Israel
- The Neuropsychological Unit, Schneider Children's Medical Center of Israel, Petach-Tikva, Israel
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22
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Levy AM, Saling MM, Anderson JFI. Frequency and extent of cognitive complaint following adult civilian mild traumatic brain injury: a systematic review and meta-analysis. BRAIN IMPAIR 2023; 24:309-332. [PMID: 38167200 DOI: 10.1017/brimp.2022.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Cognitive symptoms are associated with return to work, healthcare use and quality of life after mild traumatic brain injury (mTBI). Additionally, while overall 'post-concussion' symptoms are often present at similar levels in mTBI and control groups, cognitive complaints may be specifically elevated in mTBI. A systematic review and meta-analysis was conducted to investigate the frequency and extent of cognitive complaints following adult civilian mTBI, and compare it to the frequency and extent of complaints in control populations (PROSPERO: CRD42020151284). METHOD This review included studies published up to March 2022. Thirteen studies were included in the systematic review, and six were included in the meta-analysis. Data extraction and quality assessment were conducted by two independent reviewers. RESULTS Cognitive complaints are common after mTBI, although reported rates differed greatly across studies. Results suggested that mTBI groups report cognitive complaints to a significantly greater extent than control groups (Hedges' g = 0.85, 95% CI 0.31-1.40, p = .0102). Heterogeneity between studies was high (τ2 = 0.20, 95% CI 0.04-1.58; I2 = 75.0%, 95% CI 43.4%-89.0%). Between-group differences in symptom reporting were most often found when healthy rather than injured controls were employed. CONCLUSIONS Cognitive complaints are consistently reported after mTBI, and are present at greater levels in mTBI patients than in controls. Despite the importance of these complaints, including in regards to return to work, healthcare use and quality of life, there has been limited research in this area, and heterogeneity in research methodology is common.
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Affiliation(s)
- Arielle M Levy
- Melbourne School of Psychological Sciences, The University of Melbourne, Parkville, VIC3010, Australia
| | - Michael M Saling
- Melbourne School of Psychological Sciences, The University of Melbourne, Parkville, VIC3010, Australia
| | - Jacqueline F I Anderson
- Melbourne School of Psychological Sciences, The University of Melbourne, Parkville, VIC3010, Australia
- Psychology Department, The Alfred Hospital, Melbourne, VIC3004, Australia
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23
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Kleffelgård I, Andelic N, Bruusgaard KA, Langhammer B, Tamber AL, Soberg HL. Dizziness-Related Disability One Year after a Mild-to-Moderate TBI-A Follow-Up Study. J Clin Med 2023; 12:5192. [PMID: 37629234 PMCID: PMC10455561 DOI: 10.3390/jcm12165192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 07/29/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
Persisting dizziness and balance problems after mild-to-moderate traumatic brain injury (mmTBI) may result in considerable disability. The primary aim of this study was to explore the factors associated with dizziness-related disability one year post-injury. Data from 64 participants (mean age 39.4 [SD 13.0] years; 45 [70.3%] women) with mmTBI from a previous randomised controlled trial were analysed using simple and multiple regression analyses (Clinical Trials Registry #NCT01695577). The Dizziness Handicap Inventory one year (12.1, [SD1.6] months) post-injury was the dependent variable. Demographic and injury-related variables, clinical findings, and measures of post-injury symptoms and functioning (Rivermead Post-Concussion Symptoms Questionnaire, RPQ; Vertigo Symptom Scale-short form, VSS-SF; Hospital Anxiety and Depression Scale; Balance Error Scoring System; and High-Level Mobility Assessment Tool, HiMAT) at baseline (3.5 [SD 2.1] months post-injury) were the independent variables. Dizziness-related disability at one year was associated with pre-injury comorbidity, neck pain, higher RPQ, higher VSS-SF, and lower HiMAT scores (adjusted R2 = 0.370, F = 6.52 p < 0.001). In conclusion, the factors associated with dizziness-related disability one year post-injury, such as pre-injury comorbidity, neck pain, increased post-concussion symptom burden, increased dizziness symptom severity, and reduced balance and mobility, should be addressed early in the rehabilitation process to reduce patient burden.
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Affiliation(s)
- Ingerid Kleffelgård
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, 0424 Oslo, Norway; (N.A.); (H.L.S.)
| | - Nada Andelic
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, 0424 Oslo, Norway; (N.A.); (H.L.S.)
- Center for Habilitation and Rehabilitation Models and Services (CHARM), Institute of Health and Society, Faculty of Medicine, University of Oslo, 0316 Oslo, Norway
| | - Kari Anette Bruusgaard
- Department of Rehabilitation Science and Health Technology, Faculty of Health Sciences, Oslo Metropolitan University, 0130 Oslo, Norway; (K.A.B.); (B.L.); (A.-L.T.)
| | - Birgitta Langhammer
- Department of Rehabilitation Science and Health Technology, Faculty of Health Sciences, Oslo Metropolitan University, 0130 Oslo, Norway; (K.A.B.); (B.L.); (A.-L.T.)
| | - Anne-Lise Tamber
- Department of Rehabilitation Science and Health Technology, Faculty of Health Sciences, Oslo Metropolitan University, 0130 Oslo, Norway; (K.A.B.); (B.L.); (A.-L.T.)
| | - Helene Lundgaard Soberg
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, 0424 Oslo, Norway; (N.A.); (H.L.S.)
- Department of Rehabilitation Science and Health Technology, Faculty of Health Sciences, Oslo Metropolitan University, 0130 Oslo, Norway; (K.A.B.); (B.L.); (A.-L.T.)
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24
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Mikolić A, Steyerberg EW, Polinder S, Wilson L, Zeldovich M, von Steinbuechel N, Newcombe VF, Menon DK, van der Naalt J, Lingsma HF, Maas AI, van Klaveren D. 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. J Neurotrauma 2023; 40:1651-1670. [PMID: 37078144 PMCID: PMC10458380 DOI: 10.1089/neu.2022.0320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023] Open
Abstract
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.
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Affiliation(s)
- Ana Mikolić
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Ewout W. Steyerberg
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling, United Kingdom
| | - Marina Zeldovich
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Georg-August-University, Göttingen, Germany
| | - Nicole von Steinbuechel
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Georg-August-University, Göttingen, Germany
| | - Virginia F.J. Newcombe
- Division of Anesthesia, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - David K. Menon
- Division of Anesthesia, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Joukje van der Naalt
- Department of Neurology, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Hester F. Lingsma
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Andrew I.R. Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David van Klaveren
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands
- Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies/Tufts Medical Center, Boston, Massachusetts, USA
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25
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Mavroudis I, Ciobica A, Luca AC, Balmus IM. Post-Traumatic Headache: A Review of Prevalence, Clinical Features, Risk Factors, and Treatment Strategies. J Clin Med 2023; 12:4233. [PMID: 37445267 DOI: 10.3390/jcm12134233] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 05/23/2023] [Accepted: 06/21/2023] [Indexed: 07/15/2023] Open
Abstract
Post-traumatic headache (PTH) is a common and debilitating consequence of mild traumatic brain injury (mTBI) that can occur over one year after the head impact event. Thus, better understanding of the underlying pathophysiology and risk factors could facilitate early identification and management of PTH. There are several factors that could influence the reporting of PTH prevalence, including the definition of concussion and PTH. The main risk factors for PTHs include a history of migraines or headaches, female gender, younger age, greater severity of the head injury, and co-occurring psychological symptoms, such as anxiety and depression. PTH clinical profiles vary based on onset, duration, and severity: tension-type headache, migraine headaches, cervicogenic headache, occipital neuralgia, and new daily persistent headache. Pharmacological treatments often consist of analgesics and non-steroidal anti-inflammatory drugs, tricyclic antidepressants, or antiepileptic medication. Cognitive behavioral therapy, relaxation techniques, biofeedback, and physical therapy could also be used for PTH treatment. Our work highlighted the need for more rigorous studies to better describe the importance of identifying risk factors and patient-centered treatments and to evaluate the effectiveness of the existing treatment options. Clinicians should consider a multidisciplinary approach to managing PTH, including pharmacotherapy, cognitive behavioral therapy, and lifestyle changes.
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Affiliation(s)
- Ioannis Mavroudis
- Department of Neuroscience, Leeds Teaching Hospitals, NHS Trust, Leeds LS2 9JT, UK
- Faculty of Medicine, Leeds University, Leeds LS2 9JT, UK
| | - Alin Ciobica
- Department of Biology, Faculty of Biology, Alexandru Ioan Cuza University, 700506 Iasi, Romania
- Centre of Biomedical Research, Romanian Academy, B dul Carol I, No. 8, 700506 Iasi, Romania
- Academy of Romanian Scientists, Splaiul Independentei nr. 54, Sector 5, 050094 Bucuresti, Romania
| | - Alina Costina Luca
- Department of Mother and Child, Medicine-Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16, Universitatii Street, 700115 Iasi, Romania
| | - Ioana-Miruna Balmus
- Department of Exact Sciences and Natural Sciences, Institute of Interdisciplinary Research, "Alexandru Ioan Cuza" University of Iasi, 700057 Iasi, Romania
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Ware JB, Sandsmark DK. Imaging Approach to Concussion. Neuroimaging Clin N Am 2023; 33:261-269. [PMID: 36965944 DOI: 10.1016/j.nic.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
The acute and long-term neurobiological sequelae of concussion (mild traumatic brain injury [mTBI]) and sub-concussive head trauma have become increasingly apparent in recent decades in part due to neuroimaging research. Although imaging has an established role in the clinical management of mTBI for the identification of intracranial lesions warranting urgent interventions, MR imaging is increasingly employed for the detection of post-traumatic sequelae which carry important prognostic significance. As neuroimaging research continues to elucidate the pathophysiology of TBI underlying prolonged recovery and the development of persistent post-concussive symptoms, there is a strong motivation to translate these techniques into clinical use for improved diagnosis and therapeutic monitoring.
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Affiliation(s)
- Jeffrey B Ware
- Department of Radiology, Neuroradiology Division, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| | - Danielle K Sandsmark
- Department of Neurology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
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27
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Faulkner JW, Snell DL, Theadom A, Mahon S, Barker-Collo S. The influence of psychological flexibility on persistent post concussion symptoms and functional status after mild traumatic brain injury. Disabil Rehabil 2023; 45:1192-1201. [PMID: 35382660 DOI: 10.1080/09638288.2022.2055167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
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.
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Affiliation(s)
| | - Deborah L Snell
- Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch, New Zealand
| | - Alice Theadom
- TBI Network, Auckland University of Technology, Northcote, Auckland, New Zealand
| | - Susan Mahon
- TBI Network, Auckland University of Technology, Northcote, Auckland, New Zealand
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28
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Nelson LD, Temkin NR, Barber J, Brett BL, Okonkwo DO, McCrea MA, Giacino JT, Bodien YG, Robertson C, Corrigan JD, Diaz-Arrastia R, Markowitz AJ, Manley GT. Functional Recovery, Symptoms, and Quality of Life 1 to 5 Years After Traumatic Brain Injury. JAMA Netw Open 2023; 6:e233660. [PMID: 36939699 PMCID: PMC10028488 DOI: 10.1001/jamanetworkopen.2023.3660] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 01/21/2023] [Indexed: 03/21/2023] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | - David O. Okonkwo
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Joseph T. Giacino
- Massachusetts General Hospital and Harvard Medical School, Boston
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts
| | - Yelena G. Bodien
- Massachusetts General Hospital and Harvard Medical School, Boston
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts
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29
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Leung T, Ng XY, Alexander L, Grant A, Grahamslaw J, Pagliari C, Reed MJ, Carson A, Gillespie DC, Jamjoom AAB. A Digital Health Intervention for Concussion: Development and Clinical Feasibility Study. JMIR Form Res 2023; 7:e43557. [PMID: 36724010 PMCID: PMC9932878 DOI: 10.2196/43557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 12/07/2022] [Accepted: 12/31/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Concussion is a common condition that can lead to a constellation of symptoms that affect quality of life, social integration, and return to work. There are several evidence-based behavioral and psychological interventions that have been found to improve postconcussion symptom burden. However, these are not routinely delivered, and individuals receive limited support during their concussion recovery. OBJECTIVE This study aimed to develop and test the feasibility of a digital health intervention using a systematic evidence-, theory-, and person-based approach. METHODS This was a mixed methodology study involving a scoping review (n=21), behavioral analysis, and logic model to inform the intervention design and content. During development, the intervention was optimized with feedback from individuals who had experienced concussions (n=12) and health care professionals (n=11). The intervention was then offered to patients presenting to the emergency department with a concussion (n=50). Participants used the intervention freely and input symptom data as part of the program. A number of outcome measures were obtained, including participant engagement with the intervention, postconcussion symptom burden, and attitudes toward the intervention. A selection of participants (n=15) took part in in-depth qualitative interviews to understand their attitudes toward the intervention and how to improve it. RESULTS Engagement with the intervention functionality was 90% (45/50) for the symptom diary, 62% (31/50) for sleep time setting, 56% (28/50) for the alcohol tracker, 48% (24/50) for exercise day setting, 34% (17/50) for the thought diary, and 32% (16/50) for the goal setter. Metrics indicated high levels of early engagement that trailed off throughout the course of the intervention, with an average daily completion rate of the symptom diary of 28.23% (494/1750). A quarter of the study participants (13/50, 26%) were classified as high engagers who interacted with all the functionalities within the intervention. Quantitative and qualitative feedback indicated a high level of usability and positive perception of the intervention. Daily symptom diaries (n=494) demonstrated a wide variation in individual participant symptom burden but a decline in average burden over time. For participants with Rivermead scores on completion of HeadOn, there was a strong positive correlation (r=0.86; P<.001) between their average daily HeadOn symptom diary score and their end-of-program Rivermead score. Insights from the interviews were then fed back into development to optimize the intervention and facilitate engagement. CONCLUSIONS Using this systematic approach, we developed a digital health intervention for individuals who have experienced a concussion that is designed to facilitate positive behavior change. Symptom data input as part of the intervention provided insights into postconcussion symptom burden and recovery trajectories. TRIAL REGISTRATION ClinicalTrials.gov NCT05069948; https://clinicaltrials.gov/ct2/show/NCT05069948.
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Affiliation(s)
| | - Xin Yi Ng
- University of Edinburgh Medical School, The University of Edinburgh, Edinburgh, United Kingdom
| | - Laura Alexander
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, United Kingdom
| | - Alison Grant
- The Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Julia Grahamslaw
- The Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Claudia Pagliari
- Centre for Population Health Sciences, Usher Institute, The University of Edinburgh, Edinburgh, United Kingdom
| | - Matthew J Reed
- The Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh, Edinburgh, United Kingdom.,Acute Care Edinburgh, Usher Institute, The University of Edinburgh, Edinburgh, United Kingdom
| | - Alan Carson
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, United Kingdom
| | - David C Gillespie
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, United Kingdom
| | - Aimun A B Jamjoom
- HeadOn Health Ltd, Edinburgh, United Kingdom.,Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, United Kingdom.,Department of Clinical Neuroscience, Edinburgh Royal Infirmary, Edinburgh, United Kingdom
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30
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de Neeling M, Liessens D, Depreitere B. Relationship between psychosocial and psychiatric risk factors and poor long-term outcome following mild traumatic brain injury: A systematic review. Eur J Neurol 2023; 30:1540-1550. [PMID: 36708085 DOI: 10.1111/ene.15713] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 12/21/2022] [Accepted: 01/07/2023] [Indexed: 01/29/2023]
Abstract
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.
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Affiliation(s)
| | - Dirk Liessens
- Saint Camillus Psychiatric Center, Bierbeek, Belgium
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31
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Does insecure attachment affect treatment outcome in young persons with post-concussion symptoms? A secondary analysis of the GAIN trial. J Psychosom Res 2023; 164:111100. [PMID: 36502555 DOI: 10.1016/j.jpsychores.2022.111100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 10/27/2022] [Accepted: 11/17/2022] [Indexed: 11/21/2022]
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Sheldrake E, Lam B, Al-Hakeem H, Wheeler AL, Goldstein BI, Dunkley BT, Ameis S, Reed N, Scratch SE. A Scoping Review of Magnetic Resonance Modalities Used in Detection of Persistent Postconcussion Symptoms in Pediatric Populations. J Child Neurol 2022; 38:85-102. [PMID: 36380680 DOI: 10.1177/08830738221120741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Up to 30% of youth with concussion experience PPCSs (PPCS) lasting 4 weeks or longer, and can significantly impact quality of life. Magnetic resonance imaging (MRI) has the potential to increase understanding of causal mechanisms underlying PPCS. However, there are no clear modalities to assist in detecting PPCS. This scoping review aims to synthesize findings on utilization of MRI among children and youth with PPCS, and summarize progress and limitations. Thirty-six studies were included from 4907 identified papers. Many studies used multiple modalities, including (1) structural (n = 27) such as T1-weighted imaging, diffusion weighted imaging, and susceptibility weighted imaging; and (2) functional (n = 23) such as functional MRI and perfusion-weighted imaging. Findings were heterogeneous among modalities and regions of interest, which warrants future reviews that report on the patterns and potential advancements in the field. Consideration of modalities that target PPCS prediction and sensitive modalities that can supplement a biopsychosocial approach to PPCS would benefit future research.
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Affiliation(s)
- Elena Sheldrake
- Bloorview Research Institute, Toronto, Ontario, Canada.,Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
| | - Brendan Lam
- Bloorview Research Institute, Toronto, Ontario, Canada
| | | | - Anne L Wheeler
- Neuroscience and Mental Health Program, 7979Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Physiology, University of Toronto, Toronto, Ontario, Canada
| | - Benjamin I Goldstein
- 7978Centre for Addiction and Mental Health, Toronto, Toronto, Ontario, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Benjamin T Dunkley
- Neuroscience and Mental Health Program, 7979Hospital for Sick Children, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Stephanie Ameis
- 7978Centre for Addiction and Mental Health, Toronto, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Nick Reed
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
| | - Shannon E Scratch
- Bloorview Research Institute, Toronto, Ontario, Canada.,Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
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Prevalence of Acute Neck Pain Following Sports-Related Concussion in High School Athletes. Clin J Sport Med 2022; 32:e556-e561. [PMID: 36315823 DOI: 10.1097/jsm.0000000000001047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 12/20/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To explore the prevalence of acute neck pain in high school athletes following sports-related concussion (SRC) and to examine the role of acute neck pain in modifying or amplifying concurrent concussive symptoms. DESIGN Retrospective observational. SETTING High school sporting events. PARTICIPANTS High school athletes who suffered a sports-related concussion between the 2011 and 2019 academic years academic years from the National Athletic Treatment, Injury and Outcomes Network (NATION) Study. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Prevalence of neck pain (yes/no) along with 33 other commonly reported concussion symptoms, number of symptoms reported, mechanism of injury (contact with person/surface or object), sport type (contact/noncontact), and injury history (first time/repeated injury). RESULTS One hundred thirty-eight of 401 athletes (33.9%) indicated acute neck pain following SRC. Those with neck pain reported significantly more symptoms overall (M = 13.53, SD = 6.89) relative to their non-neck pain counterparts (M = 8.46, SD = 5.68; t [191.35] = 7.11, P < 0.001). Athletes with SRC due to contact with a surface were significantly less likely to report neck pain than those reported contact with a person. Neck pain, repeated injury, and female sex were significantly associated with a greater number of concussion symptoms in the acute phase. CONCLUSIONS Our data suggest that acute neck pain is a frequent acute symptom following SRC and signals the necessity for additional screening to seek and identify comorbid cervical pathology. Prospective studies should seek to access the benefit of cervical therapy in the early stages in SRC patients with neck pain to reduce the risk of persistent postconcussion symptoms.
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Dizziness Is Associated With Neck/Shoulder Pain Following Pediatric Concussion. Clin J Sport Med 2022; 32:e562-e567. [PMID: 36315824 DOI: 10.1097/jsm.0000000000001054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/19/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To examine the association between dizziness and neck/shoulder pain after concussion and if differences in postural stability and oculomotor function exist among patients reporting dizziness with or without concurrent neck/shoulder pain. DESIGN Cross sectional. SETTING Sports medicine clinic. PATIENTS Pediatric patients ≤14 days post concussion. INTERVENTIONS N/A. OUTCOME MEASURES Patients completed the Health and Behavior Inventory (HBI) symptom rating and separately rated neck/shoulder pain (scale 0-3; 0 = no pain). We grouped patients by HBI dizziness rating (0 = not-dizzy; 1-3 = dizzy) and compared neck/shoulder pain ratings between the groups. We then compared oculomotor and postural stability outcomes between dizzy patients with and without neck/shoulder pain. RESULTS We included 153 patients: dizzy (n = 100; age = 14.6 ± 2.2 years; 48% female) and not-dizzy (n = 53, age = 14.4 ± 3.1 years; 38% female). The dizzy group reported significantly higher neck/shoulder pain (1.4 ± 1.1 vs 0.5 ± 0.9 points, P < 0.001) and total symptom score (25.7 ± 11.2 vs 11.7 ± 9.3 points, P < 0.001) than the not-dizzy group. After adjusting for total symptom score and preinjury anxiety, depression, and migraines, dizziness was associated with higher odds of neck/shoulder pain (odds ratio = 1.9, 95% CI, 1.2-3.0; P = 0.004). No differences were observed between dizzy patients with and without neck/shoulder pain for near point of convergence (10.0 ± 7.5 vs 8.5 ± 6.7 cm, P = 0.43), modified Balance Error Scoring System (8.9 ± 5.5 vs 6.8 ± 4.7 errors, P = 0.09), or tandem gait (single-task: 26.0 ± 12.3 vs 24.2 ± 11.9 seconds, P = 0.56; dual-task: 35.1 ± 14.3 vs 35.6 ± 18.6 seconds, P = 0.90). CONCLUSIONS In concussion patients experiencing dizziness, evaluating neck/shoulder pain may help identify individuals who would benefit from cervical spine rehabilitation. However, other potential causes of dizziness should also be evaluated to facilitate timely recovery.
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Maas AIR, Menon DK, Manley GT, Abrams M, Åkerlund C, Andelic N, Aries M, Bashford T, Bell MJ, Bodien YG, Brett BL, Büki A, Chesnut RM, Citerio G, Clark D, Clasby B, Cooper DJ, Czeiter E, Czosnyka M, Dams-O’Connor K, De Keyser V, Diaz-Arrastia R, Ercole A, van Essen TA, Falvey É, Ferguson AR, Figaji A, Fitzgerald M, Foreman B, Gantner D, Gao G, Giacino J, Gravesteijn B, Guiza F, Gupta D, Gurnell M, Haagsma JA, Hammond FM, Hawryluk G, Hutchinson P, van der Jagt M, Jain S, Jain S, Jiang JY, Kent H, Kolias A, Kompanje EJO, Lecky F, Lingsma HF, Maegele M, Majdan M, Markowitz A, McCrea M, Meyfroidt G, Mikolić A, Mondello S, Mukherjee P, Nelson D, Nelson LD, Newcombe V, Okonkwo D, Orešič M, Peul W, Pisică D, Polinder S, Ponsford J, Puybasset L, Raj R, Robba C, Røe C, Rosand J, Schueler P, Sharp DJ, Smielewski P, Stein MB, von Steinbüchel N, Stewart W, Steyerberg EW, Stocchetti N, Temkin N, Tenovuo O, Theadom A, Thomas I, Espin AT, Turgeon AF, Unterberg A, Van Praag D, van Veen E, Verheyden J, Vyvere TV, Wang KKW, Wiegers EJA, Williams WH, Wilson L, Wisniewski SR, Younsi A, Yue JK, Yuh EL, Zeiler FA, Zeldovich M, Zemek R. Traumatic brain injury: progress and challenges in prevention, clinical care, and research. Lancet Neurol 2022; 21:1004-1060. [PMID: 36183712 PMCID: PMC10427240 DOI: 10.1016/s1474-4422(22)00309-x] [Citation(s) in RCA: 255] [Impact Index Per Article: 127.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 07/22/2022] [Indexed: 02/06/2023]
Abstract
Traumatic brain injury (TBI) has the highest incidence of all common neurological disorders, and poses a substantial public health burden. TBI is increasingly documented not only as an acute condition but also as a chronic disease with long-term consequences, including an increased risk of late-onset neurodegeneration. The first Lancet Neurology Commission on TBI, published in 2017, called for a concerted effort to tackle the global health problem posed by TBI. Since then, funding agencies have supported research both in high-income countries (HICs) and in low-income and middle-income countries (LMICs). In November 2020, the World Health Assembly, the decision-making body of WHO, passed resolution WHA73.10 for global actions on epilepsy and other neurological disorders, and WHO launched the Decade for Action on Road Safety plan in 2021. New knowledge has been generated by large observational studies, including those conducted under the umbrella of the International Traumatic Brain Injury Research (InTBIR) initiative, established as a collaboration of funding agencies in 2011. InTBIR has also provided a huge stimulus to collaborative research in TBI and has facilitated participation of global partners. The return on investment has been high, but many needs of patients with TBI remain unaddressed. This update to the 2017 Commission presents advances and discusses persisting and new challenges in prevention, clinical care, and research. In LMICs, the occurrence of TBI is driven by road traffic incidents, often involving vulnerable road users such as motorcyclists and pedestrians. In HICs, most TBI is caused by falls, particularly in older people (aged ≥65 years), who often have comorbidities. Risk factors such as frailty and alcohol misuse provide opportunities for targeted prevention actions. Little evidence exists to inform treatment of older patients, who have been commonly excluded from past clinical trials—consequently, appropriate evidence is urgently required. Although increasing age is associated with worse outcomes from TBI, age should not dictate limitations in therapy. However, patients injured by low-energy falls (who are mostly older people) are about 50% less likely to receive critical care or emergency interventions, compared with those injured by high-energy mechanisms, such as road traffic incidents. Mild TBI, defined as a Glasgow Coma sum score of 13–15, comprises most of the TBI cases (over 90%) presenting to hospital. Around 50% of adult patients with mild TBI presenting to hospital do not recover to pre-TBI levels of health by 6 months after their injury. Fewer than 10% of patients discharged after presenting to an emergency department for TBI in Europe currently receive follow-up. Structured follow-up after mild TBI should be considered good practice, and urgent research is needed to identify which patients with mild TBI are at risk for incomplete recovery. The selection of patients for CT is an important triage decision in mild TBI since it allows early identification of lesions that can trigger hospital admission or life-saving surgery. Current decision making for deciding on CT is inefficient, with 90–95% of scanned patients showing no intracranial injury but being subjected to radiation risks. InTBIR studies have shown that measurement of blood-based biomarkers adds value to previously proposed clinical decision rules, holding the potential to improve efficiency while reducing radiation exposure. Increased concentrations of biomarkers in the blood of patients with a normal presentation CT scan suggest structural brain damage, which is seen on MR scanning in up to 30% of patients with mild TBI. Advanced MRI, including diffusion tensor imaging and volumetric analyses, can identify additional injuries not detectable by visual inspection of standard clinical MR images. Thus, the absence of CT abnormalities does not exclude structural damage—an observation relevant to litigation procedures, to management of mild TBI, and when CT scans are insufficient to explain the severity of the clinical condition. Although blood-based protein biomarkers have been shown to have important roles in the evaluation of TBI, most available assays are for research use only. To date, there is only one vendor of such assays with regulatory clearance in Europe and the USA with an indication to rule out the need for CT imaging for patients with suspected TBI. Regulatory clearance is provided for a combination of biomarkers, although evidence is accumulating that a single biomarker can perform as well as a combination. Additional biomarkers and more clinical-use platforms are on the horizon, but cross-platform harmonisation of results is needed. Health-care efficiency would benefit from diversity in providers. In the intensive care setting, automated analysis of blood pressure and intracranial pressure with calculation of derived parameters can help individualise management of TBI. Interest in the identification of subgroups of patients who might benefit more from some specific therapeutic approaches than others represents a welcome shift towards precision medicine. Comparative-effectiveness research to identify best practice has delivered on expectations for providing evidence in support of best practices, both in adult and paediatric patients with TBI. Progress has also been made in improving outcome assessment after TBI. Key instruments have been translated into up to 20 languages and linguistically validated, and are now internationally available for clinical and research use. TBI affects multiple domains of functioning, and outcomes are affected by personal characteristics and life-course events, consistent with a multifactorial bio-psycho-socio-ecological model of TBI, as presented in the US National Academies of Sciences, Engineering, and Medicine (NASEM) 2022 report. Multidimensional assessment is desirable and might be best based on measurement of global functional impairment. More work is required to develop and implement recommendations for multidimensional assessment. Prediction of outcome is relevant to patients and their families, and can facilitate the benchmarking of quality of care. InTBIR studies have identified new building blocks (eg, blood biomarkers and quantitative CT analysis) to refine existing prognostic models. Further improvement in prognostication could come from MRI, genetics, and the integration of dynamic changes in patient status after presentation. Neurotrauma researchers traditionally seek translation of their research findings through publications, clinical guidelines, and industry collaborations. However, to effectively impact clinical care and outcome, interactions are also needed with research funders, regulators, and policy makers, and partnership with patient organisations. Such interactions are increasingly taking place, with exemplars including interactions with the All Party Parliamentary Group on Acquired Brain Injury in the UK, the production of the NASEM report in the USA, and interactions with the US Food and Drug Administration. More interactions should be encouraged, and future discussions with regulators should include debates around consent from patients with acute mental incapacity and data sharing. Data sharing is strongly advocated by funding agencies. From January 2023, the US National Institutes of Health will require upload of research data into public repositories, but the EU requires data controllers to safeguard data security and privacy regulation. The tension between open data-sharing and adherence to privacy regulation could be resolved by cross-dataset analyses on federated platforms, with the data remaining at their original safe location. Tools already exist for conventional statistical analyses on federated platforms, however federated machine learning requires further development. Support for further development of federated platforms, and neuroinformatics more generally, should be a priority. This update to the 2017 Commission presents new insights and challenges across a range of topics around TBI: epidemiology and prevention (section 1 ); system of care (section 2 ); clinical management (section 3 ); characterisation of TBI (section 4 ); outcome assessment (section 5 ); prognosis (Section 6 ); and new directions for acquiring and implementing evidence (section 7 ). Table 1 summarises key messages from this Commission and proposes recommendations for the way forward to advance research and clinical management of TBI.
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Affiliation(s)
- Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Mathew Abrams
- International Neuroinformatics Coordinating Facility, Karolinska Institutet, Stockholm, Sweden
| | - Cecilia Åkerlund
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Nada Andelic
- Division of Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Marcel Aries
- Department of Intensive Care, Maastricht UMC, Maastricht, Netherlands
| | - Tom Bashford
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Michael J Bell
- Critical Care Medicine, Neurological Surgery and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Yelena G Bodien
- Department of Neurology and Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
| | - Benjamin L Brett
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - András Büki
- Department of Neurosurgery, Faculty of Medicine and Health Örebro University, Örebro, Sweden
- Department of Neurosurgery, Medical School; ELKH-PTE Clinical Neuroscience MR Research Group; and Neurotrauma Research Group, Janos Szentagothai Research Centre, University of Pecs, Pecs, Hungary
| | - Randall M Chesnut
- Department of Neurological Surgery and Department of Orthopaedics and Sports Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, Universita Milano Bicocca, Milan, Italy
- NeuroIntensive Care, San Gerardo Hospital, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
| | - David Clark
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Betony Clasby
- Department of Sociological Studies, University of Sheffield, Sheffield, UK
| | - D Jamie Cooper
- School of Public Health and Preventive Medicine, Monash University and The Alfred Hospital, Melbourne, VIC, Australia
| | - Endre Czeiter
- Department of Neurosurgery, Medical School; ELKH-PTE Clinical Neuroscience MR Research Group; and Neurotrauma Research Group, Janos Szentagothai Research Centre, University of Pecs, Pecs, Hungary
| | - Marek Czosnyka
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Kristen Dams-O’Connor
- Department of Rehabilitation and Human Performance and Department of Neurology, Brain Injury Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Véronique De Keyser
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Ramon Diaz-Arrastia
- Department of Neurology and Center for Brain Injury and Repair, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Thomas A van Essen
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
- Department of Neurosurgery, Medical Center Haaglanden, The Hague, Netherlands
| | - Éanna Falvey
- College of Medicine and Health, University College Cork, Cork, Ireland
| | - Adam R Ferguson
- Brain and Spinal Injury Center, Department of Neurological Surgery, Weill Institute for Neurosciences, University of California San Francisco and San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA
| | - Anthony Figaji
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Curtin University, Bentley, WA, Australia
- Perron Institute for Neurological and Translational Sciences, Nedlands, WA, Australia
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, University of Cincinnati, Cincinnati, OH, USA
| | - Dashiell Gantner
- School of Public Health and Preventive Medicine, Monash University and The Alfred Hospital, Melbourne, VIC, Australia
| | - Guoyi Gao
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine
| | - Joseph Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School and Spaulding Rehabilitation Hospital, Charlestown, MA, USA
| | - Benjamin Gravesteijn
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Fabian Guiza
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Deepak Gupta
- Department of Neurosurgery, Neurosciences Centre and JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Mark Gurnell
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Juanita A Haagsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Flora M Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
| | - Gregory Hawryluk
- Section of Neurosurgery, GB1, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Peter Hutchinson
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Mathieu van der Jagt
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Sonia Jain
- Biostatistics Research Center, Herbert Wertheim School of Public Health, University of California, San Diego, CA, USA
| | - Swati Jain
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Ji-yao Jiang
- Department of Neurosurgery, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hope Kent
- Department of Psychology, University of Exeter, Exeter, UK
| | - Angelos Kolias
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Erwin J O Kompanje
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Marc Maegele
- Cologne-Merheim Medical Center, Department of Trauma and Orthopedic Surgery, Witten/Herdecke University, Cologne, Germany
| | - Marek Majdan
- Institute for Global Health and Epidemiology, Department of Public Health, Faculty of Health Sciences and Social Work, Trnava University, Trnava, Slovakia
| | - Amy Markowitz
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Michael McCrea
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Ana Mikolić
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Pratik Mukherjee
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - David Nelson
- Section for Anesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Lindsay D Nelson
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Virginia Newcombe
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - David Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matej Orešič
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Wilco Peul
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
| | - Dana Pisică
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jennie Ponsford
- Monash-Epworth Rehabilitation Research Centre, Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, VIC, Australia
| | - Louis Puybasset
- Department of Anesthesiology and Intensive Care, APHP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Chiara Robba
- Department of Anaesthesia and Intensive Care, Policlinico San Martino IRCCS for Oncology and Neuroscience, Genova, Italy, and Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Italy
| | - Cecilie Røe
- Division of Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Jonathan Rosand
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - David J Sharp
- Department of Brain Sciences, Imperial College London, London, UK
| | - Peter Smielewski
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Murray B Stein
- Department of Psychiatry and Department of Family Medicine and Public Health, UCSD School of Medicine, La Jolla, CA, USA
| | - Nicole von Steinbüchel
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Goettingen, Germany
| | - William Stewart
- Department of Neuropathology, Queen Elizabeth University Hospital and University of Glasgow, Glasgow, UK
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences Leiden University Medical Center, Leiden, Netherlands
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, Milan University, and Neuroscience ICU, Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nancy Temkin
- Departments of Neurological Surgery, and Biostatistics, University of Washington, Seattle, WA, USA
| | - Olli Tenovuo
- Department of Rehabilitation and Brain Trauma, Turku University Hospital, and Department of Neurology, University of Turku, Turku, Finland
| | - Alice Theadom
- National Institute for Stroke and Applied Neurosciences, Faculty of Health and Environmental Studies, Auckland University of Technology, Auckland, New Zealand
| | - Ilias Thomas
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Abel Torres Espin
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, CHU de Québec-Université Laval Research Center, Québec City, QC, Canada
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Dominique Van Praag
- Departments of Clinical Psychology and Neurosurgery, Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Ernest van Veen
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | - Thijs Vande Vyvere
- Department of Radiology, Faculty of Medicine and Health Sciences, Department of Rehabilitation Sciences (MOVANT), Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Kevin K W Wang
- Department of Psychiatry, University of Florida, Gainesville, FL, USA
| | - Eveline J A Wiegers
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - W Huw Williams
- Centre for Clinical Neuropsychology Research, Department of Psychology, University of Exeter, Exeter, UK
| | - Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling, UK
| | - Stephen R Wisniewski
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Alexander Younsi
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - John K Yue
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Esther L Yuh
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Frederick A Zeiler
- Departments of Surgery, Human Anatomy and Cell Science, and Biomedical Engineering, Rady Faculty of Health Sciences and Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Marina Zeldovich
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Goettingen, Germany
| | - Roger Zemek
- Departments of Pediatrics and Emergency Medicine, University of Ottawa, Children’s Hospital of Eastern Ontario, ON, Canada
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Le Sage N, Chauny JM, Berthelot S, Archambault P, Neveu X, Moore L, Boucher V, Frenette J, De Guise É, Ouellet MC, Lee J, McRae AD, Lang E, Émond M, Mercier É, Tardif PA, Swaine B, Cameron P, Perry JJ. Post-Concussion Symptoms Rule: Derivation and Validation of a Clinical Decision Rule for Early Prediction of Persistent Symptoms after a Mild Traumatic Brain Injury. J Neurotrauma 2022; 39:1349-1362. [PMID: 35765917 PMCID: PMC9529302 DOI: 10.1089/neu.2022.0026] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Mild traumatic brain injury (mTBI) is a common problem. Depending on diagnostic criteria, 13 to 62% of those patients develop persistent post-concussion symptoms (PPCS). The main objective of this prospective multi-center study is to derive and validate a clinical decision rule (CDR) for the early prediction of PPCS. Patients aged ≥14 years were included if they presented to one of our seven participating emergency departments (EDs) within 24 h of an mTBI. Clinical data were collected in the ED, and symptom evolution was assessed at 7, 30 and 90 days post-injury using the Rivermead Post-Concussion Questionnaire (RPQ). The primary outcome was PPCS at 90 days after mTBI. A predictive model called the Post-Concussion Symptoms Rule (PoCS Rule) was developed using the methodological standards for CDR. Of the 1083 analyzed patients (471 and 612 for the derivation and validation cohorts, respectively), 15.6% had PPCS. The final model included the following factors assessed in the ED: age, sex, history of prior TBI or mental health disorder, headache in ED, cervical sprain and hemorrhage on computed tomography. The 7-day follow-up identified additional risk factors: headaches, sleep disturbance, fatigue, sensitivity to light, and RPQ ≥21. The PoCS Rule had a sensitivity of 91.4% and 89.6%, a specificity of 53.8% and 44.7% and a negative predictive value of 97.2% and 95.8% in the derivation and validation cohorts, respectively. The PoCS Rule will help emergency physicians quickly stratify the risk of PPCS in mTBI patients and better plan post-discharge resources.
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Affiliation(s)
- Natalie Le Sage
- CHU de Québec-Université Laval Research Centre, Université Laval, Québec, Canada
- VITAM-Centre de recherche en santé durable, Université Laval, Québec, Canada
| | - Jean-Marc Chauny
- Department of Emergency Medicine, Université de Montréal, Quebec, Canada
| | - Simon Berthelot
- CHU de Québec-Université Laval Research Centre, Université Laval, Québec, Canada
| | - Patrick Archambault
- CHU de Québec-Université Laval Research Centre, Université Laval, Québec, Canada
| | - Xavier Neveu
- CHU de Québec-Université Laval Research Centre, Université Laval, Québec, Canada
| | - Lynne Moore
- CHU de Québec-Université Laval Research Centre, Université Laval, Québec, Canada
| | - Valérie Boucher
- CHU de Québec-Université Laval Research Centre, Université Laval, Québec, Canada
| | - Jérôme Frenette
- CHU de Québec-Université Laval Research Centre, Université Laval, Québec, Canada
| | - Élaine De Guise
- Department of Emergency Medicine, McGill University, Québec, Canada
| | | | - Jacques Lee
- Department of Emergency Medicine, University of Toronto, Ontario, Canada
| | - Andrew D. McRae
- Department of Emergency Medicine, University of Calgary, Alberta, Canada
| | - Eddy Lang
- Department of Emergency Medicine, University of Calgary, Alberta, Canada
| | - Marcel Émond
- CHU de Québec-Université Laval Research Centre, Université Laval, Québec, Canada
| | - Éric Mercier
- CHU de Québec-Université Laval Research Centre, Université Laval, Québec, Canada
| | | | - Bonnie Swaine
- Department of Emergency Medicine, Université de Montréal, Quebec, Canada
| | - Peter Cameron
- Department of Epidemiology and Preventive Medicine, Monash University Melbourne, Victoria, Australia
| | - Jeffrey J. Perry
- Department of Emergency Medicine, Ottawa Hospital Research Institute, Ontario, Canada
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Glutamate, GABA and glutathione in adults with persistent post-concussive symptoms. Neuroimage Clin 2022; 36:103152. [PMID: 36007438 PMCID: PMC9424629 DOI: 10.1016/j.nicl.2022.103152] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/23/2022] [Accepted: 08/12/2022] [Indexed: 12/14/2022]
Abstract
Persistent post-concussive symptoms (PPCS) are debilitating and endure beyond the usual recovery period after mild traumatic brain injury (mTBI). Altered neurotransmission, impaired energy metabolism and oxidative stress have been examined acutely post-injury but have not been explored extensively in those with persistent symptoms. Specifically, the antioxidant glutathione (GSH) and the excitatory and inhibitory metabolites, glutamate (Glu) and γ-aminobutyric acid (GABA), are seldom studied together in the clinical mTBI literature. While Glu can be measured using conventional magnetic resonance spectroscopy (MRS) methods at 3 Tesla, GABA and GSH require the use of advanced MRS methods. Here, we used the recently established Hadamard Encoding and Reconstruction of MEGA-Edited Spectroscopy (HERMES) to simultaneously measure GSH and GABA and short-echo time point resolved spectroscopy (PRESS) to measure Glu to gain new insight into the pathophysiology of PPCS. Twenty-nine adults with PPCS (mean age: 45.69 years, s.d.: 10.73, 22 females, 7 males) and 29 age- and sex-matched controls (mean age: 43.69 years, s.d.: 11.00) completed magnetic resonance spectroscopy scans with voxels placed in the anterior cingulate and right sensorimotor cortex. Relative to controls, anterior cingulate Glu was significantly reduced in PPCS. Higher anterior cingulate GABA was significantly associated with a higher number of lifetime mTBIs, suggesting GABA may be upregulated with repeated incidence of mTBI. Furthermore, GSH in both regions of interest was positively associated with symptoms of sleepiness and headache burden. Collectively, our findings suggest that the antioxidant defense system is active in participants with PPCS, however this may be at the expense of other glutamatergic functions such as cortical excitation and energy metabolism.
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Joyce JM, La PL, Walker R, Harris A. Magnetic resonance spectroscopy of traumatic brain injury and subconcussive hits: A systematic review and meta-analysis. J Neurotrauma 2022; 39:1455-1476. [PMID: 35838132 DOI: 10.1089/neu.2022.0125] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Magnetic resonance spectroscopy (MRS) is a non-invasive technique used to study metabolites in the brain. MRS findings in traumatic brain injury (TBI) and subconcussive hit literature have been mixed. The most common observation is a decrease in N-acetyl-aspartate (NAA), traditionally considered a marker of neuronal integrity. Other metabolites, however, such as creatine (Cr), choline (Cho), glutamate+glutamine (Glx) and myo-inositol (mI) have shown inconsistent changes in these populations. The objective of this systematic review and meta-analysis was to synthesize MRS literature in head injury and explore factors (brain region, injury severity, time since injury, demographic, technical imaging factors, etc.) that may contribute to differential findings. One hundred and thirty-eight studies met inclusion criteria for the systematic review and of those, 62 NAA, 24 Cr, 49 Cho, 18 Glx and 21 mI studies met inclusion criteria for meta-analysis. A random effects model was used for meta-analyses with brain region as a subgroup for each of the five metabolites studied. Meta-regression was used to examine the influence of potential moderators including injury severity, time since injury, age, sex, tissue composition and methodological factors. In this analysis of 1428 unique head-injured subjects and 1132 controls, the corpus callosum was identified as a brain region highly susceptible to metabolite alteration. NAA was consistently decreased in TBI of all severity, but not in subconcussive hits. Cho and mI were found to be increased in moderate-to-severe TBI but not mild TBI. Glx and Cr were largely unaffected, however did show alterations in certain conditions.
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Affiliation(s)
- Julie Michele Joyce
- University of Calgary, 2129, Radiology, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, 157742, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, 157744, Calgary, Alberta, Canada.,Integrated Concussion Research Program, Calgary, Alberta, Canada;
| | - Parker L La
- University of Calgary, 2129, Radiology, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, 157742, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, 157744, Calgary, Alberta, Canada.,Integrated Concussion Research Program, Calgary, Alberta, Canada;
| | - Robyn Walker
- University of Calgary, 2129, Radiology, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, 157742, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, 157744, Calgary, Alberta, Canada.,Integrated Concussion Research Program, Calgary, Alberta, Canada;
| | - Ashley Harris
- University of Calgary, Radiology, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, 157742, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, 157744, Calgary, Alberta, Canada.,Integrated Concussion Research Program, Calgary, Alberta, Canada;
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Rivera D, Greving S, Arango-Lasprilla JC, von Steinbuechel N, Zeldovich M. Comparability of (Post-Concussion) Symptoms across Time in Individuals after Traumatic Brain Injury: Results from the CENTER-TBI Study. J Clin Med 2022; 11:jcm11144090. [PMID: 35887853 PMCID: PMC9322034 DOI: 10.3390/jcm11144090] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/10/2022] [Accepted: 07/13/2022] [Indexed: 02/04/2023] Open
Abstract
Post-concussion symptoms often occur after TBI, persist and cause disabilities. The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) is widely used in this population, but little is known about the comparability of the symptoms over time, i.e., longitudinal measurement invariance (MI). The objectives of this study were to analyze the longitudinal MI of RPQ symptoms from three to twelve months after TBI and to find factors related to RPQ symptoms. The study involved 1023 individuals after TBI who took part in the Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study and completed the RPQ at three, six and twelve months post-injury. Longitudinal confirmatory factor analysis showed that the three-factor structure (somatic, emotional and cognitive) remains stable within one year after TBI. Linear mixed models revealed that sex, injury cause and prior psychiatric problems were related to the RPQ three-factor structure as well as to the RPQ total score. The study strengthens evidence for the RPQ’s factorial structure stability within one year after TBI and identifies sex, injury cause and prior psychiatric problems as important factors that may help clinicians to prevent future complications of symptomatology after TBI.
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Affiliation(s)
- Diego Rivera
- Department of Health Sciences, Public University of Navarre, Arrosadia Campus, 31006 Pamplona, Spain;
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), Irunlarrea Street 3, 31008 Pamplona, Spain
| | - Sven Greving
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany; (S.G.); (N.v.S.)
| | | | - Nicole von Steinbuechel
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany; (S.G.); (N.v.S.)
| | - Marina Zeldovich
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany; (S.G.); (N.v.S.)
- Correspondence:
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Coffeng SM, Jacobs B, Kim LJ, Ter Maaten JC, van der Naalt J. Incomplete recovery in patients with minor head injury directly discharged home from the emergency department: a prospective cohort follow-up study. BMJ Open 2022; 12:e057308. [PMID: 35768088 PMCID: PMC9244716 DOI: 10.1136/bmjopen-2021-057308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES To determine the frequency of post-traumatic complaints and recovery rate of non-hospitalised patients with minor head injury (MHI) and their relationship with demographic and injury characteristics. We also evaluated the differences between patient groups in this least severe category of brain and head injury. DESIGN Prospective cohort follow-up study. SETTING Patients admitted to the emergency department (ED) of a tertiary hospital in the Netherlands. PARTICIPANTS 242 patients with MHI (n=100 with head injury only and n=142 with mild traumatic brain injury (mTBI)) discharged home directly after evaluation at the ED. OUTCOME MEASURES The primary outcome measure was incomplete recovery at 3 months measured by the Glasgow Outcome Scale-Extended score <8. Secondary outcome measures were number of post-traumatic complaints assessed 2 weeks and 3 months postinjury by a standardised questionnaire. Also the number of patients that visited their general practitioner because of persistent complaints was determined. RESULTS Three months postinjury 48% of patients reported more than one post-traumatic complaint. Half (51%) of patients showed incomplete recovery. Incomplete recovery was associated with headache directly postinjury (OR 3.27, 95% CI 1.28 to 8.34), age (OR 1.02, 95% CI 1.00 to 1.05) and the number of post-traumatic complaints (OR 1.24, 95% CI 1.09 to 1.40) and depression (OR 6.31, 95% CI 1.24 to 32.00) 2 weeks postinjury. Incomplete recovery was comparable between the head injury only and mTBI group (55% vs 50%, 95% CI -12.5 to -23.0). In total 36 MHI patients (28%) visited their general practitioner because of complaints related to their head injury. CONCLUSION Half of the non-hospitalised patients with MHI experienced incomplete recovery after 3 months without differences between head injury only and mTBI patients. Therefore, early identification of patients at risk for incomplete recovery must be started at the ED to provide appropriate aftercare to avoid long-term post-traumatic complaints.
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Affiliation(s)
- Sophie Maria Coffeng
- Department of Emergency Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Bram Jacobs
- Department of Neurology, University Medical Center Groningen, Groningen, The Netherlands
| | - Laura Jane Kim
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan Cornelis Ter Maaten
- Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Joukje van der Naalt
- Department of Neurology, University Medical Center Groningen, Groningen, The Netherlands
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Characteristics of Responders and Nonresponders in a Military Postconcussion Rehabilitation Program. J Head Trauma Rehabil 2022; 37:E458-E466. [PMID: 35617677 DOI: 10.1097/htr.0000000000000792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To characterize treatment responders and nonresponders as measured by the Neurobehavioral Symptom Inventory (NSI) in order to understand whether certain traits in our patient population would characterize favorable response. SETTING Brain Injury Rehabilitation Service at Brooke Army Medical Center, Fort Sam Houston, San Antonio, Texas. PATIENTS In total, 655 active duty military patients with a diagnosis of mild traumatic brain injury (mTBI) who received treatment between 2007 and 2020 and completed self-report measures as part of routine care. DESIGN Observational retrospective analysis of outpatient clinical outcomes data. MAIN MEASURES The primary outcome measure was the NSI, divided into the responder and nonresponder groups. Responders were defined by reliable change in NSI total score (decrease of ≥8 points from intake to discharge). FINDINGS Responders (n = 395) reported a higher level of symptom burden at intake on the NSI. Women responded proportionally more (70%) than men (58%). After treatment, responders reported improvements on all measures evaluated while nonresponders reported no change or slightly worse symptoms. Logistic regression analysis showed that posttraumatic stress symptoms at intake decreased odds of favorable treatment response while satisfaction with social relationships increased odds of favorable treatment response. CONCLUSION The results from this process improvement project suggested that posttraumatic symptoms warrant programmatic attention in TBI clinics while social relationships may be a protective factor that can be capitalized to enhance troop readiness. Systematic examination of these characteristics should be conducted on a larger population within the military health system.
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Legarda SB, Lahti CE, McDermott D, Michas-Martin A. Use of Novel Concussion Protocol With Infralow Frequency Neuromodulation Demonstrates Significant Treatment Response in Patients With Persistent Postconcussion Symptoms, a Retrospective Study. Front Hum Neurosci 2022; 16:894758. [PMID: 35685335 PMCID: PMC9170890 DOI: 10.3389/fnhum.2022.894758] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 04/20/2022] [Indexed: 01/28/2023] Open
Abstract
Introduction Concussion is a growing public health concern. No uniformly established therapy exists; neurofeedback studies report treatment value. We use infralow frequency neuromodulation (ILF) to remediate disabling neurological symptoms caused by traumatic brain injury (TBI) and noted improved outcomes with a novel concussion protocol. Postconcussion symptoms (PCS) and persistent postconcussion symptoms (PPCS; >3 months post head injury) are designated timelines for protracted neurological complaints following TBI. We performed a retrospective study to explore effectiveness of ILF in PCS/PPCS and investigated the value of using this concussion protocol. Method Patients with PCS/PPCS seen for their first neurology office visit or received their first neurofeedback session between 1 August 2018 and 31 January 2021 were entered. Outcomes were compared following treatment as usual (TAU) vs. TAU with ILF neurotherapy (TAU+ILF). The study cohort was limited to PPCS patients; the TAU+ILF group was restricted further to PPCS patients receiving at least 10 neurotherapy sessions. Within the TAU+ILF group, comparisons were made between those who trained at least 10 sessions using concussion protocol (TAU+ILF+CP) and those who trained for at least 10 sessions of ILF regardless of protocol (TAU+ILF-CP). Results Among our resultant PPCS cohort (n = 59) leading persistent neurological complaints were headache (67.8%), memory impairment (57.6%), and brain fog (50.8%). PPCS patients in TAU+ILF+CP (n = 25) demonstrated greater net (p = 0.004) and percent (p = 0.026) improvement of symptoms compared to PPCS subjects in TAU (n = 26). PPCS patients in TAU+ILF-CP (n = 8) trended toward significant symptom improvements compared to TAU, and TAU+ILF+CP trended toward greater efficacy than TAU+ILF-CP. Conclusion PPCS patients who received TAU+ILF+CP demonstrated significantly greater improvement as a group when compared to TAU. When used as an integrative modality to treatment as usual in managing patients with PPCS, ILF neuromodulation with use of concussion protocol provided significant symptom improvements.
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Affiliation(s)
- Stella B. Legarda
- Neurology, Montage Health, Montage Medical Group, Monterey, CA, United States
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Posti JP, Tenovuo O. Blood-based biomarkers and traumatic brain injury-A clinical perspective. Acta Neurol Scand 2022; 146:389-399. [PMID: 35383879 DOI: 10.1111/ane.13620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 03/08/2022] [Accepted: 03/27/2022] [Indexed: 12/19/2022]
Abstract
Blood-based biomarkers are promising tools to complement clinical variables and imaging findings in the diagnosis, monitoring and outcome prediction of traumatic brain injury (TBI). Several promising biomarker candidates have been found for various clinical questions, but the translation of TBI biomarkers into clinical applications has been negligible. Measured biomarker levels are influenced by patient-related variables such as age, blood-brain barrier integrity and renal and liver function. It is not yet fully understood how biomarkers enter the bloodstream from the interstitial fluid of the brain. In addition, the diagnostic performance of TBI biomarkers is affected by sampling timing and analytical methods. In this focused review, the clinical aspects of glial fibrillary acidic protein, neurofilament light, S100 calcium-binding protein B, tau and ubiquitin C-terminal hydrolase-L1 are examined. Current findings and clinical caveats are addressed.
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Affiliation(s)
- Jussi P. Posti
- Neurocenter Department of Neurosurgery and Turku Brain Injury Center Turku University Hospital and University of Turku Turku Finland
| | - Olli Tenovuo
- Neurocenter Turku Brain Injury Center Turku University Hospital and University of Turku Turku Finland
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Karr JE, Williams MW, Iverson GL, Huang SJ, Yang CC. Pre-Injury headache and post-traumatic headache in patients with mild traumatic brain injury: neuropsychological, psychiatric, and post-concussion symptom outcomes. Brain Inj 2022; 36:175-182. [PMID: 35226574 DOI: 10.1080/02699052.2022.2043440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
PRIMARY OBJECTIVE Headache, both before and after injury, has been associated with worse outcome following mild traumatic brain injury (MTBI). This study examined whether three MTBI patient groups - no headache (reported no pre-/post-injury headache), pre-injury headache (reported pre-injury headache, nearly all of whom also reported post-injury headache), and post-traumatic headache only (denied pre-injury headache and reported post-injury headache) - differed in acute-to-subacute outcomes. RESEARCH DESIGN Cross-sectional observational study. METHODS AND PROCEDURES Patients within 21 days of a MTBI (n = 291) completed neuropsychological tests and questionnaires evaluating depression, anxiety, and post-concussion symptoms. MAIN OUTCOMES AND RESULTS Neuropsychological test performances did not differ between headache groups. Participants with pre-injury headache and participants with post-traumatic headache only reported greater change in self-reported physical and cognitive symptoms than participants with no headache. Participants with pre-injury headache reported worse post-injury anxiety symptoms than participants with post-traumatic headache only. CONCLUSIONS The pre-injury headache and post-traumatic headache only groups did not meaningfully differ in outcome within 21 days of MTBI, but they had worse physical and cognitive symptoms than participants with no headache. Future research should assess whether differences in outcome emerge further from injury and whether specific headache subtypes are differentially associated with outcome.
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Affiliation(s)
- Justin E Karr
- Department of Psychology, University of Kentucky, Lexington, Kentucky, USA
| | | | - Grant L Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA.,Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA.,Spaulding Research Institute, Charlestown, Massachusetts, USA.,Home Base, a Red Sox Foundation and Massachusetts General Hospital Program, Charlestown, Massachusetts, USA
| | | | - Chi-Cheng Yang
- Department of Psychology, National Chengchi University, Taipei, Taiwan.,Holistic Mental Health Center, Taipei City Hospital, Taipei, Taiwan
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Karaliute M, Saksvik SB, Smevik H, Follestad T, Einarsen C, Vik A, Håberg AK, Iverson GL, Skandsen T, Olsen A. Methodology Matters: Comparing Approaches for Defining Persistent Symptoms after Mild Traumatic Brain Injury. Neurotrauma Rep 2022; 2:603-617. [PMID: 35018362 PMCID: PMC8742292 DOI: 10.1089/neur.2021.0028] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Some people experience persistent post-concussion symptoms (PPCS) after mild traumatic brain injury (mTBI). A meaningful clinical classification and scientific progress are hampered by a lack of consensus regarding the phenomenology, assessment, and operationalization of PPCS. Here we demonstrate and evaluate how the methodology used to assess and define persistent symptoms after mTBI influences PPCS as a binary outcome. We present empirical data from 15 classification methods reflecting procedures found in the literature and clinical practice. In total, 221 patients with mTBI, 73 patients with orthopedic injuries, and 77 community controls were included in the study. The prevalence rate of PPCS in the mTBI group varied between 10% and 47%, depending on the method used to assess and define unfavorable outcome. There was generally low positive agreement between the different methods; even the two methods yielding the most similar prevalence rates (89.2% overall proportion agreement) agreed on less than half (45.5% positive agreement) of the PPCS cases. Using a liberal but not uncommon threshold for symptom severity, there was a considerable misclassification rate of PPCS in both comparison groups. Our results highlight the importance for researchers to be aware of the limitations of using binary approaches for classification of PPCS. The poor agreement between methods should be considered when (1) interpreting the heterogeneity in the existing PPCS literature and (2) developing new improved methods. An empirically informed consensus regarding classification of PPCS should be a priority for the research community.
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Affiliation(s)
- Migle Karaliute
- Department of Psychology, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,Department of Neurology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Simen B Saksvik
- Department of Psychology, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,Department of Physical Medicine and Rehabilitation, and St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Hanne Smevik
- Department of Psychology, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Turid Follestad
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, and Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Cathrine Einarsen
- Department of Physical Medicine and Rehabilitation, and St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Anne Vik
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,Department of Neurosurgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Asta K Håberg
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Grant L Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School; Spaulding Rehabilitation Hospital and Spaulding Research Institute; MassGeneral Hospital for Children Sports Concussion Program; & Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Charlestown, Massachusetts, USA
| | - Toril Skandsen
- Department of Physical Medicine and Rehabilitation, and St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Alexander Olsen
- Department of Psychology, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,Department of Physical Medicine and Rehabilitation, and St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Malik S, Alnaji O, Malik M, Gambale T, Rathbone MP. Correlation between Mild Traumatic Brain Injury-Induced Inflammatory Cytokines and Emotional Symptom Traits: A Systematic Review. Brain Sci 2022; 12:brainsci12010102. [PMID: 35053845 PMCID: PMC8773760 DOI: 10.3390/brainsci12010102] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 01/04/2022] [Accepted: 01/05/2022] [Indexed: 01/09/2023] Open
Abstract
Both mild traumatic brain injuries (mTBI) and systemic injuries trigger a transient neuroinflammatory response that result in similar clinical outcome. The ensuing physical, cognitive, and emotional symptoms fail to subside in approximately 15–20% of the concussed population. Emotional impairments, particularly depression, anxiety, and post-traumatic stress disorder (PTSD), are commonly associated with poor recovery following mTBI. These emotional impairments also have a significant neuroinflammatory component. We hypothesized that the inflammatory cytokines seen in mTBI patients with emotional symptoms would coincide with those commonly seen in patients with emotional symptoms without mTBI. A systematic review was conducted to identify the most common neuroinflammatory cytokines in the mTBI population with psychological symptoms (depression, anxiety, PTSD). The electronic databases EMBASE, MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), PUBMED, and PSYCINFO were searched from data inception to 31 August 2021. A systematic screening approach was employed from screening to data analysis. A total of 994 articles were screened, 108 were selected for full article review, and 8 were selected for data analysis. The included studies consisted of 875 patients of which 81.3% were male. The mean sample size of patients with at least one mTBI was 73.8 ± 70.3 (range, 9–213), with a mean age of 33.9 ± 4.8 years. The most common cytokines associated with poor psychological outcomes involving PTSD and/or depression in the chronic mTBI population were IL-6, TNFα, IL-10, and CRP.
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Affiliation(s)
- Shazia Malik
- Neurosciences Graduate Program, McMaster University, Hamilton, ON L8S 4L8, Canada
- Correspondence:
| | - Omar Alnaji
- Faculty of Life Sciences, McMaster University, Hamilton, ON L8S 4L8, Canada;
| | - Mahnoor Malik
- Bachelor of Health Sciences Program, McMaster University, Hamilton, ON L8S 4L8, Canada;
| | - Teresa Gambale
- Division of Neurology, Department of Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada; (T.G.); (M.P.R.)
| | - Michel Piers Rathbone
- Division of Neurology, Department of Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada; (T.G.); (M.P.R.)
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Bittencourt M, Balart-Sánchez SA, Maurits NM, van der Naalt J. Self-Reported Complaints as Prognostic Markers for Outcome After Mild Traumatic Brain Injury in Elderly: A Machine Learning Approach. Front Neurol 2021; 12:751539. [PMID: 34925214 PMCID: PMC8674199 DOI: 10.3389/fneur.2021.751539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 10/26/2021] [Indexed: 11/13/2022] Open
Abstract
Self-reported complaints are common after mild traumatic brain injury (mTBI). Particularly in the elderly with mTBI, the pre-injury status might play a relevant role in the recovery process. In most mTBI studies, however, pre-injury complaints are neither analyzed nor are the elderly included. Here, we aimed to identify which individual pre- and post-injury complaints are potential prognostic markers for incomplete recovery (IR) in elderly patients who sustained an mTBI. Since patients report many complaints across several domains that are strongly related, we used an interpretable machine learning (ML) approach to robustly deal with correlated predictors and boost classification performance. Pre- and post-injury levels of 20 individual complaints, as self-reported in the acute phase, were analyzed. We used data from two independent studies separately: UPFRONT study was used for training and validation and ReCONNECT study for independent testing. Functional outcome was assessed with the Glasgow Outcome Scale Extended (GOSE). We dichotomized functional outcome into complete recovery (CR; GOSE = 8) and IR (GOSE ≤ 7). In total 148 elderly with mTBI (median age: 67 years, interquartile range [IQR]: 9 years; UPFRONT: N = 115; ReCONNECT: N = 33) were included in this study. IR was observed in 74 (50%) patients. The classification model (IR vs. CR) achieved a good performance (the area under the receiver operating characteristic curve [ROC-AUC] = 0.80; 95% CI: 0.74-0.86) based on a subset of only 8 out of 40 pre- and post-injury complaints. We identified increased neck pain (p = 0.001) from pre- to post-injury as the strongest predictor of IR, followed by increased irritability (p = 0.011) and increased forgetfulness (p = 0.035) from pre- to post-injury. Our findings indicate that a subset of pre- and post-injury physical, emotional, and cognitive complaints has predictive value for determining long-term functional outcomes in elderly patients with mTBI. Particularly, post-injury neck pain, irritability, and forgetfulness scores were associated with IR and should be assessed early. The application of an ML approach holds promise for application in self-reported questionnaires to predict outcomes after mTBI.
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Affiliation(s)
- Mayra Bittencourt
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Sebastián A Balart-Sánchez
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Natasha M Maurits
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Joukje van der Naalt
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
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Narducci DM, Moran B, Coris E, Tsalatsanis A, Graulich I, Del Rossi G. Predicting Concussion Recovery with PHQ-9 and GAD-7. South Med J 2021; 114:760-765. [PMID: 34853851 DOI: 10.14423/smj.0000000000001336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine whether scores obtained from Patient Health Questionnaire-9 (PHQ-9) or the General Anxiety Disorder-7 (GAD-7) instruments administered following a concussion can be used to predict recovery time. METHOD Retrospective cohort study in a university-based specialty concussion center of 502 concussed participants. Participants completed a PHQ-9 and GAD-7 during their initial visit and subsequent visits during the recovery period (ie, at 14, 28, 56, and 84 days). RESULTS The median recovery time from a concussion was 21 days from the initial clinical evaluation; however, individuals with a PHQ-9 score ≤ 6 (n = 262) had a median recovery time of 17 (95% confidence interval [CI] 15-19) days, whereas those with PHQ-9 scores >6 (n = 240) had a median recovery time of 33 (95% CI 28-37) days and a hazard ratio of 0.525 (95% CI 0.438-0.629, P < 0.0001). For individuals with a GAD-7 score ≤ 4 (n = 259), the median recovery was 19 (95% CI 17-21), days whereas for those with a GAD-7 score > 4 (n = 243), the median recovery was 32 (95% CI 28-36) days with a hazard ratio of 0.554 (95% CI 0.462-0.664, P < 0.00). CONCLUSIONS Scores obtained from PHQ-9 and GAD-7 screening tools appear to be predictive of an individual's recovery and may help identify those subjects who may benefit from early psychological interventions.
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Affiliation(s)
- Dusty Marie Narducci
- From the Department of Family Medicine, University of South Florida Morsani College of Medicine, Department of Family Medicine, College of Medicine Office of Research, and Department of Orthopedics, University of South Florida, Tampa, Florida, and Department of Physical Therapy, Creighton University, Phoenix, Arizona
| | - Byron Moran
- From the Department of Family Medicine, University of South Florida Morsani College of Medicine, Department of Family Medicine, College of Medicine Office of Research, and Department of Orthopedics, University of South Florida, Tampa, Florida, and Department of Physical Therapy, Creighton University, Phoenix, Arizona
| | - Eric Coris
- From the Department of Family Medicine, University of South Florida Morsani College of Medicine, Department of Family Medicine, College of Medicine Office of Research, and Department of Orthopedics, University of South Florida, Tampa, Florida, and Department of Physical Therapy, Creighton University, Phoenix, Arizona
| | - Athanasios Tsalatsanis
- From the Department of Family Medicine, University of South Florida Morsani College of Medicine, Department of Family Medicine, College of Medicine Office of Research, and Department of Orthopedics, University of South Florida, Tampa, Florida, and Department of Physical Therapy, Creighton University, Phoenix, Arizona
| | - Ian Graulich
- From the Department of Family Medicine, University of South Florida Morsani College of Medicine, Department of Family Medicine, College of Medicine Office of Research, and Department of Orthopedics, University of South Florida, Tampa, Florida, and Department of Physical Therapy, Creighton University, Phoenix, Arizona
| | - Gianluca Del Rossi
- From the Department of Family Medicine, University of South Florida Morsani College of Medicine, Department of Family Medicine, College of Medicine Office of Research, and Department of Orthopedics, University of South Florida, Tampa, Florida, and Department of Physical Therapy, Creighton University, Phoenix, Arizona
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Rytter HM, Graff HJ, Henriksen HK, Aaen N, Hartvigsen J, Hoegh M, Nisted I, Næss-Schmidt ET, Pedersen LL, Schytz HW, Thastum MM, Zerlang B, Callesen HE. Nonpharmacological Treatment of Persistent Postconcussion Symptoms in Adults: A Systematic Review and Meta-analysis and Guideline Recommendation. JAMA Netw Open 2021; 4:e2132221. [PMID: 34751759 PMCID: PMC8579233 DOI: 10.1001/jamanetworkopen.2021.32221] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
IMPORTANCE Persistent (>4 weeks) postconcussion symptoms (PPCS) are challenging for both patients and clinicians. There is uncertainty about the effect of commonly applied nonpharmacological treatments for the management of PPCS. OBJECTIVE To systematically assess and summarize evidence for outcomes related to 7 nonpharmacological interventions for PPCS in adults (aged >18 years) and provide recommendations for clinical practice. DATA SOURCES Systematic literature searches were performed via Embase, MEDLINE, PsycINFO, CINAHL, PEDro, OTseeker, and Cochrane Reviews (via MEDLINE and Embase) from earliest possible publication year to March 3, 2020. The literature was searched for prior systematic reviews and primary studies. To be included, studies had to be intervention studies with a control group and focus on PPCS. STUDY SELECTION A multidisciplinary guideline panel selected interventions based on frequency of use and need for decision support among clinicians, including early information and advice, graded physical exercise, vestibular rehabilitation, manual treatment of neck and back, oculomotor vision treatment, psychological treatment, and interdisciplinary coordinated rehabilitative treatment. To be included, studies had to be intervention studies within the areas of the predefined clinical questions, include a control group, and focus on symptoms after concussion or mild traumatic brain injury. DATA EXTRACTION AND SYNTHESIS Extraction was performed independently by multiple observers. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used for data abstraction and data quality assessment. Included studies were assessed using the Assessment of Multiple Systematic Reviews (AMSTAR) tool and the Cochrane Risk of Bias (randomized clinical trials) tool. Meta-analysis was performed for all interventions where possible. Random-effects models were used to calculate pooled estimates of effects. The level and certainty of evidence was rated and recommendations formulated according to the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. MAIN OUTCOMES AND MEASURES All outcomes were planned before data collection began according to a specified protocol. The primary outcomes were the collective burden of PPCS and another outcome reflecting the focus of a particular intervention (eg, physical functioning after graded exercise intervention). RESULTS Eleven systematic reviews were identified but did not contribute any primary studies; 19 randomized clinical trials comprising 2007 participants (1064 women [53.0%]) were separately identified and included. Evidence for the 7 interventions ranged from no evidence meeting the inclusion criteria to very low and low levels of evidence. Recommendations were weak for early information and advice, graded physical exercise, vestibular rehabilitation, manual treatment of the neck and back, psychological treatment, and interdisciplinary coordinated rehabilitative treatment. No relevant evidence was identified for oculomotor vision treatment, so the panel provided a good clinical practice recommendation based on consensus. CONCLUSIONS AND RELEVANCE Based on very low to low certainty of evidence or based on consensus, the guideline panel found weak scientific support for commonly applied nonpharmacological interventions to treat PPCS. Results align with recommendations in international guidelines. Intensified research into all types of intervention for PPCS is needed.
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Affiliation(s)
- Hana Malá Rytter
- Danish Concussion Center, Copenhagen, Denmark
- Department of Psychology, University of Copenhagen, Copenhagen, Denmark
- Department of Neurology, Bispebjerg-Frederiksberg University Hospital, Copenhagen, Denmark
| | | | - Henriette K. Henriksen
- Danish Concussion Center, Copenhagen, Denmark
- Center for Rehabilitation of Brain Injury, Copenhagen, Denmark
| | - Nicolai Aaen
- The Danish Concussion Association, Copenhagen, Denmark
| | - Jan Hartvigsen
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
- Chiropractic Knowledge Hub, Odense, Denmark
| | - Morten Hoegh
- Musculoskeletal Health and Implementation, Department of Medicine, Aalborg University, Aalborg, Denmark
- Pain Science Educator, Aarhus, Denmark
| | - Ivan Nisted
- Danish College of Optometry, Dania Academy, Randers, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | | | - Henrik Winther Schytz
- Danish Headache Center, Rigshospitalet-Glostrup, University of Copenhagen, Copenhagen, Denmark
| | - Mille Møller Thastum
- Hammel Neurorehabilitation Centre–University Clinic for Neurorehabilitation, Aarhus University, Aarhus, Denmark
| | - Bente Zerlang
- Exercise and Health Training Center, Roskilde Municipality, Roskilde, Denmark
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Tuborgh A, Svendsen SW, Elklit A, Hunter J, Jensen JS, Schröder A, Nielsen JF, Thastum MM, Næss-Schmidt ET, Rask CU. Attachment and symptom reporting in adolescents and young adults after a concussion. J Psychosom Res 2021; 150:110603. [PMID: 34509710 DOI: 10.1016/j.jpsychores.2021.110603] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 08/25/2021] [Accepted: 08/27/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The incidence of hospital-treated concussion is 100-300/100,000 person years. Reporting of long-lasting post-concussion symptoms (PCS) is estimated at 5-15%. Attachment insecurity is a potential vulnerability factor for physical illness and poorer disease outcomes in general. This study aimed to explore associations between attachment insecurity and PCS in young people sustaining a concussion. METHODS This cross-sectional study was embedded in a cohort of 15-30-year-old patients (n = 3080) 3 months after sustaining a concussion. Data were obtained from a database and questionnaires. PCS were measured by the Rivermead Post-Concussion Symptoms Questionnaire and attachment dimensions (anxiety and avoidance) by the Experiences in Close Relationships-Relationship Structures Questionnaire. Multiple linear regression models were performed to investigate the association between the attachment dimensions and PCS with adjustment for demographic, injury-related and psychological factors and with additional testing for interaction between the attachment dimensions. RESULTS In the final study sample, comprising 973 patients (31.6%), we found an interaction between the attachment dimensions. Hence, the effect of attachment anxiety on PCS was statistically insignificant at low avoidance (25th percentile) but significant at high avoidance (75th percentile, β = 0.64 (95%CI: 0.02; 1.26)), whereas the effect of attachment avoidance was significant regardless of level of attachment anxiety (25th percentile, β = 1.09 (95%CI: 0.18; 2.01); 75th percentile, β = 2.71 (95%CI: 1.80; 3.61)). CONCLUSION Attachment insecurity, especially characterised by high avoidance in combination with high anxiety, also called fearful attachment, is associated with PCS. Considering the attachment perspective can potentially improve health care for this patient group.
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Affiliation(s)
- A Tuborgh
- Department of Child and Adolescent Psychiatry, Research Unit, Aarhus University Hospital, Psychiatry, Denmark; Department of Clinical Medicine, Aarhus University, Denmark.
| | - S W Svendsen
- Hammel Neurorehabilitation Centre, University Research Clinic, Aarhus University, Denmark; Department of Occupational and Environmental Medicine, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Denmark; Department of Public Health, Section of Environmental Health, University of Copenhagen, Denmark
| | - A Elklit
- Department of Psychology, National Centre of Psycho-traumatology, University of Southern Denmark, Denmark
| | - J Hunter
- Department of Psychiatry, Sinai Health System, University of Toronto, Canada
| | - J S Jensen
- Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Denmark
| | - A Schröder
- Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Denmark
| | - J F Nielsen
- Hammel Neurorehabilitation Centre, University Research Clinic, Aarhus University, Denmark
| | - M M Thastum
- Hammel Neurorehabilitation Centre, University Research Clinic, Aarhus University, Denmark; Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Denmark
| | - E T Næss-Schmidt
- Hammel Neurorehabilitation Centre, University Research Clinic, Aarhus University, Denmark
| | - C U Rask
- Department of Child and Adolescent Psychiatry, Research Unit, Aarhus University Hospital, Psychiatry, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
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