Anxiety, Depression, and Quality of Life: A Long-Term Follow-Up Study of Patients with Persisting Concussion Symptoms

After the buzzer sounds: Adults unveil the consequences of concussions sustained during adolescence

Concussions are commonly occurring injuries in sport. The short-term impacts of concussions, including symptoms and recovery trajectories, often are the focus of concussion research. However, limited studies have explored the long-term consequences of concussions, especially in adolescents. The purpose of this study was to explore adults' experiences with concussions sustained during their adolescence (5-15 years prior). This qualitative study was guided by an interpretivist philosophy. Twenty young adults (11 men, 9 women, median age 26) who had sustained at least one sport-related concussion during their adolescence participated in a one-on-one semi-structured interview. We aimed to explore their experiences with their concussion at the time of injury and any consequences they experienced as a result of their concussion. We organized participants' concussion experiences into six main themes: (1) Concussion diagnosis and experiences with health care providers; (2) Emotional symptoms following concussion; (3) Concussion recovery; (4) Change in sport participation and engagement; (5) Concern about the potential long-term consequences; and (6) Impact on social relationships. We used the Biopsychosocial Model of Sport Injury Rehabilitation to organize the themes. Future research should explore how acute multi-disciplinary support could reduce the negative long-term consequences of concussion in adolescents.

Factors associated with anxiety and depression one year after trauma critical care admission: A multi-centre study

BACKGROUND

Recovery after severe injury may be impacted by a range of psychological factors. This multi-site study investigated the prevalence and impact of anxiety and depression at one year after trauma critical care admission.

METHODS

Adult trauma patients admitted to four Level 1 Critical Care Units were prospectively enrolled over 18 months. Survivors were followed-up at one year post discharge using EQ-5D-5L questionnaires. Multivariable logistic regression analysis was used to evaluate factors associated with anxiety and depression at follow up.

RESULTS

Of the 657 patients consented and alive at follow-up, 290 questionnaires were completed (44 % response rate). Two-thirds (63 %) reported anxiety or depression (AoD) at follow up, and this was associated with a worse overall health state (EQ-VAS No AoD: 80 vs. AoD: 60, p < 0.0001). Median ISS in both groups was 25 but those with AoD were younger (53 years vs. 60 years, p = 0.033), had previous psychological morbidities (16 % vs. 5 %, p = 0.0056) and longer hospital stays (32 vs. 24 days, p = 0.0027). All physical EQ-5D-5 L domains were worse in the presence of AoD and problems increased as anxiety or depression became more severe. Factors associated with anxiety and depression were younger age (OR 0.98 [95 % CI 0.96-0.99] p = 0.004), previous psychological morbidity (OR 3.30 [95 % CI 1.51-7.40] p = 0.004), penetrating injury (OR 10.10 [95 % CI 1.90 - 44.4] p = 0.007), ongoing pain (OR 1.61 [95 % CI 1.10-2.30] p = 0.003) or difficulties carrying out usual activities (OR 1.40 [95 % CI 1.02-2.29] p = 0.04).

CONCLUSION

Anxiety and depression are significant longer-term impacts after severe injury. Younger age, penetrating injury and psychological comorbidities may be identifiers of longer-term anxiety and depression following trauma critical care. Pain at one-year had a strong association and represents a modifiable target to improve psychological outcomes.

Functional network disruptions in youth with concussion using the Adolescent Brain Cognitive Development study

OBJECTIVE

This study aimed to compare psychosocial outcomes and functional neuroimaging among youth with concussion, youth with anxiety, and age- and sex-matched controls.

METHODS

Using archival data from the Adolescent Brain Cognitive DevelopmentSM Study, we analyzed between-group differences in psychosocial outcomes measured by the Child Behavior Checklist's internalizing and externalizing problem scales, and assessed brain function using resting-state fMRI network-region connectivity (specifically frontoparietal network (FPN) and default mode network (DMN) connectivity with the amygdala).

RESULTS

Significant differences in psychosocial outcomes were found across all groups, with the anxiety group reporting the most internalizing problems, followed by the concussion group which significantly differed from controls. Additionally, FPN-amygdala connectivity was significantly reduced in the concussion group only; this reduced connectivity did not predict psychosocial outcomes across groups.

CONCLUSION

This study provided preliminary findings that brain connectivity is reduced exclusively in individuals with concussion. Although disruptions were observed in the concussion group, further investigation is warranted to understand how disruptions may be associated with concussion symptoms. Studies that utilize well-defined control and study groups, and comprehensive cognitive and mental health measures will offer a deeper understanding of the relationship between brain function and psychosocial outcomes.

Accommodative and Vergence Responses to a Moving Stimulus in Concussion

Purpose

Concussed adolescents often report visual symptoms, especially for moving targets, but the mechanisms resulting in oculomotor deficits remain unclear. We objectively measured accommodative and vergence responses to a moving target in concussed adolescents and controls.

Methods

Thirty-two symptomatic concussed participants (mean age, 14.4 ± 2.6 years; mean days since concussion, 107 days; range, 36-273 days) and 32 healthy controls (mean age, 12.7 ± 2.1 years) viewed a movie binocularly (closed-loop) and monocularly (vergence open-loop), as well as a Difference of Gaussians (DoG) target binocularly (accommodation open-loop). The movie or DoG target sinusoidally moved toward and away from participants at a 0.1-hertz (Hz) frequency at four separate stimulus amplitudes (1.50 diopters [D], 1.00 D, 0.50 D, 0.25 D) around a 2.50-D midpoint. Accommodation and vergence were continuously measured at 50 Hz using the PowerRef 3. Fourier analysis was used to assess the response amplitudes at the 0.1-Hz frequency. A 2 × 3 analysis of variance with the factors group (concussed, control) and viewing condition (binocular, monocular, DoG) was conducted on response amplitudes.

Results

Across groups, accommodative and vergence responses were significantly higher in binocular than monocular conditions (P < 0.001), but not DoG conditions. Compared to controls, concussed participants had significantly reduced monocular accommodative responses (P < 0.012; e.g., at 1.50 D, controls = 1.09 ± 0.47 D and concussed = 0.80 ± 0.36 D, P = 0.011). No group differences were observed for vergence responses in any viewing condition.

Conclusions

Accommodative and vergence responses to the moving target were largely driven by disparity cues for both groups, with only minimal improvements in the presence of additional blur cues. Concussed participants showed reduced accommodative responses to a 0.1-Hz stimulus in monocular conditions, indicating mild accommodative deficits in the absence of disparity cues.

Predicting chronic post-traumatic head and neck pain: the role of bedside parameters

ABSTRACT

Traumatic brain injury (TBI) annually impacts 69 million individuals worldwide. Mild TBI constitutes approximately 90% of all TBIs. Chronic pain post-mTBI occurs in 29% to 58% of patients. This study aims to introduce a predictive model for chronic pain development in individuals diagnosed with mild traumatic brain injury (mTBI) immediately postinjury. We included individuals who had sustained mTBI in motor vehicle accident (MVA). All patients had initial assessments within the first 72 hours (representing the subacute period) after the injury and performed follow-ups for 1 year. Machine learning model was applied to the integrated measures of clinical pain, pain-related psychological parameters, mTBI clinical signs, and sociodemographic information. This study included 203 patients experiencing acute head or neck pain attributable to mTBI post-MVA. We categorized these patients into 2 groups: patients who progressed to develop chronic head or neck pain (n = 89, 43.8%) and patients who recovered (low/mild pain) (n = 114, 56.2%). Severity of the subacute neck pain, number of painful body areas, and education years were identified as the most significant factors predicting chronic pain. The optimized predictive model demonstrated high efficacy, with an accuracy of 83%, a sensitivity of 92%, and an area under the receiver operating characteristic curve of 0.8. Our findings indicate feasibility in predicting chronic post-MVA pain within the critical 72-hour window postinjury using simple bedside metrics. This approach offers a promising avenue for the early detection of individuals at increased risk for chronic pain, enabling the implementation of targeted early interventions.

Critical gap in practice-lack of attention to falls and possible fall-related post-concussion symptoms in older adults and individuals with neurodegenerative disease

Falls in older adults and those with neurodegenerative disease (ND) are a current public health hazard and the primary cause of sustaining a mild traumatic brain injury (mTBI)/concussion. Little is known regarding how post-concussion symptoms present in older adults and patients with ND, even though they are the demographic at highest risk. A combination of under-reporting of falls and a lack of awareness regarding potential consequences of falls, results in the underdiagnosis of post-fall issues and concussions in this population. Our aim was to conduct a quality assessment survey to assess physician practice regarding falls and their general knowledge of concussion symptoms. We sent surveys through email to 1400 North American physicians, mostly those working at university affiliated hospitals, who specialized in seeing older adults and patients with ND. One hundred forty-one physicians completed the survey. 71.4% of all responding physicians either never inquired or inquired in less than 5% of their patients with ND or older adult patients, about history of falls. Over half of the physicians (51.8%) either never ask or do not consider it necessary to ask about concussion symptoms post-fall. The majority of physicians (92%) recognized that concussions can have lasting effects on patients, particularly on mood and demonstrated good knowledge of post-concussion symptoms by correctly identifying them. Additionally, more than 70% of responding physicians believed that patients with ND or older adults can fully recover from a concussion with the same probability as any other age group if treated. Only 50% of physicians felt confident in managing post-concussion symptoms themselves, 53.9% of physicians did not know of, or did not have nearby concussion clinics to refer patients to. The gaps in practice are clearly reflective of the gaps in the literature regarding falls and concussions in older adults and ND patients. There is a very low rate of physician inquiry about history of falls and concussion symptoms in older patients and those with NDs. Failure to recognize a concussion, can lead to missed opportunities for targeted interventions to address reversible symptoms. Additionally, the misattribution of post-concussion symptoms to disease progression in older patients or those with NDs may delay and hinder appropriate management.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

"I hope it'll get better… in the end, it didn't really get better": a qualitative study of access to specialized rehabilitation services as experienced by adults with persistent MTBI symptoms

PURPOSE

Persistent symptoms experienced by adults following mild traumatic brain injury (mTBI) can significantly impact their daily activities. It is often difficult for them to access specialized rehabilitation services. The aim of this study is to explore this population's experience surrounding access to specialized rehabilitation services, including waiting time.

MATERIALS AND METHODS

This study used a qualitative phenomenological approach and was conducted using semi-structured interviews. Twelve adults with mTBI who had received specialized interdisciplinary rehabilitation services were recruited. The interviews focused on participants' recollection of their patient journey after injury, their perception of waiting, barriers and facilitators to access, and the impacts of these experiences on their condition.

RESULTS

Participants reported experiencing symptoms such as anxiety, depression, worry, sadness, and discouragement before accessing specialized services. They all agreed that they did not receive clear information about their recovery process or the health services available to them, which exacerbated their mental health symptoms.

CONCLUSION

The findings show that participants experienced uncertainty because they lacked information regarding recovery and access to health services after their injury. Education about symptoms and recovery, as well as emotional support for people with mTBI should be made available during the waiting period.

Athletic Fear Avoidance in Athletes Receiving Rehabilitation for Sport-Related Concussion: A Preliminary Study

BACKGROUND

Fear avoidance after musculoskeletal injury is avoiding activity due to fear of pain and contributes to persistent symptoms, depression, and disability. Little is known about fear avoidance for sport (athletic fear avoidance) in athletes with sport-related concussion (SRC).

HYPOTHESIS

Athletic fear avoidance after SRC would be elevated at the start of rehabilitation, improve over time, and be associated with postconcussion recovery outcomes.

STUDY DESIGN

Observational study.

LEVEL OF EVIDENCE

Level 4.

METHODS

Athletes in rehabilitation after SRC participated. Testing at initial and discharge visits and 6-month follow-up included Athletic Fear Avoidance Questionnaire (AFAQ), Postconcussion Symptom Scale (PCSS), Profile of Mood States (POMS), and Dizziness Handicap Inventory (DHI). Differences were explored in AFAQ score at initial testing based on sex or age (<18 or ≥18 years). Change in questionnaire scores over time was examined. Association of AFAQ score with other questionnaire scores was determined at each timepoint.

RESULTS

A total of 48 athletes participated: 28 completed initial testing only (INITIAL ONLY), and 20 completed all testing (LONGITUDINAL). Across cohorts, the mean (SD) AFAQ score at initial testing was 24.3 (7.6) points, with no significant difference by sex or age. AFAQ, PCSS, POMS, and DHI scores improved in LONGITUDINAL; the effect size was large from initial to discharge testing (1.0, 1.0, 1.0, and 1.2, respectively) and variable from discharge to follow-up testing (0.52, -0.34, -0.08, and 0.02, respectively). AFAQ scores increased from discharge to follow-up in 3 athletes and were consistently above the mean value in 2 athletes. AFAQ score was significantly correlated to the other questionnaire scores at each timepoint (range, r = 0.36-0.75).

CONCLUSION

Athletic fear avoidance was elevated at the start of SRC rehabilitation, improved over time in most patients, and was associated with postconcussion symptoms, mood, and disability.

CLINICAL RELEVANCE

Athletic fear avoidance may impact recovery after SRC.

Mental health and lower urinary tract symptoms: Results from the NHANES and Mendelian randomization study

BACKGROUND

The clinical observations suggest a correlation between lower urinary tract symptoms (LUTSs) and mental health problems. Nonetheless, establishing a direct causal relationship between them remains challenging.

METHODS

We initially conducted a cross-sectional study using 2005-2018 the National Health and Nutrition Examination Survey (NHANES) data. Multivariable-adjusted logistic regression was the primary statistical approach. Additionally, we employed Mendelian randomization (MR) to reducing confounding and reverse causation. Genetic instruments were obtained from publicly available genome-wide association study (GWAS) databases. Inverse Variance Weighted was the primary statistical method.

RESULTS

The cross-sectional study involved 29,439 participants. Individuals with mental health problems had a higher risk of urinary incontinence (OR:4.38; 95%CI:3.32-5.76; P < 0.01) and overactive bladder (OR:2.31; 95%CI:2.02-2.63; P < 0.01). MR analysis then indicated a potential causal relationship between mental health problems and LUTSs. Depression symptoms was linked with urinary tract infection (UTI) (OR:1.005; 95%CI:1.003-1.008; PFDR < 0.01). Anxiety symptoms was related to the occurrence of UTI (OR:1.024; 95%CI:1.011-1.037; PFDR < 0.01) and bladder calcified/ contracted/ overactive (OR:1.017; 95%CI:1.007-1.027; PFDR < 0.01). The personality trait of neuroticism was related to the occurrence of cystitis (OR:1.072; 95%CI:1.022-1.125; PFDR = 0.02), extravasation of urine and difficulties with micturition (OR:1.001; 95%CI:1.001-1.002; PFDR < 0.01), and urinary frequency and incontinence (OR: 1.001; 95%CI:1.000-1.001; PFDR < 0.01).

CONCLUSIONS

Our study provides various evidence for the correlation between mental health and LUTSs, emphasizing the significance of adopting a holistic approach to LUTSs management that incorporates both physical and psychological factors.

Relations between concussion symptoms and depression among patients with mild traumatic brain injury: A moderated mediation model

INTRODUCTION

Concussion symptoms following a traumatic accident are both common and known to adversely affect mental health and recovery in patients with traumatic brain injury. Depression, highly prevalent among patients with traumatic brain injury, is also associated with the important factors of sleep quality and resilience. However, the mediator and moderator roles of depression following concussion in patients with traumatic brain injury have been underexplored. The aims of this study were to investigate the mediating role of sleep quality in the relation between concussion symptoms and depression and to examine the moderating effect of resilience on this mediated model.

DESIGN

Cross-sectional pretest data analysis of a randomized controlled trial.

METHODS

A total of 249 adult patients with mild traumatic brain injury (Glasgow Coma Scale 13-15) at admission following brain injury were surveyed at a medical center in Taipei, Taiwan. The outcome variables were concussion symptoms (Rivermead Post-Concussion Symptom Questionnaire), sleep quality (Pittsburgh Sleep Quality Index), resilience (Resilience Scale for Adults), and depression (Beck Depression Inventory II). These data were analyzed using moderated mediation regressions with the SPSS PROCESS macro.

RESULTS

In patients with mild traumatic brain injury, there was a significant positive relation between concussion symptoms and depression, of which sleep quality was a significant mediator. Additionally, resilience had a negative moderating effect on the relations between sleep quality and depression. Patients with less resilience showed a stronger negative effect of sleep quality on depression.

CONCLUSION

Our findings suggest that ameliorating both concussion symptoms and sleep disturbance is important for reducing the risk of depression in patients with mild traumatic brain injury, especially in those patients with less resilience.

CLINICAL RELEVANCE

It is essential for clinical nurses to develop interventions for patients with mild traumatic brain injury that will improve their sleep quality, while strengthening their resilience, to alleviate depression.

Labour market attachment dynamics in patients with concussion: a Danish nationwide register-based cohort study

BACKGROUND

Concussion may lead to persisting post-concussive symptoms affecting work ability and employment. This study examined the transitions between labour market states an individual can experience after the acute phase of concussion. The aim was to describe the incidence of favourable and adverse transitions between different labour market states (e.g., employment, sick leave) in relation to socioeconomic and health characteristics in individuals with concussion relative to matched controls.

METHODS

This Danish nationwide register-based cohort study extracted 18-60-year-old individuals between 2003-2007 with concussion from the Danish National Patient Register (ICD-10 S06.0). Controls were matched on age, sex, and municipality. Patients and controls were followed for 5 years starting three months after injury. Exclusion criteria were neurological injuries and unavailability to the labour market in the inclusion period (2003-2007) and 5-years before injury (1998-2002). Labour market states were defined from transfer income data in the Danish Register for Evaluation of Marginalization. Incidence rates of transitions between these labour market states were analysed in multistate models. Transitions were bundled in favourable and adverse transitions between labour market states and the difference in incidence rates between individuals with concussion relative to matched controls were assessed with hazard ratios from Cox regression models.

RESULTS

Persons with concussion (n = 15.580) had a lower incidence of favourable transitions (HR 0.88, CI 0.86-0.90) and a higher incidence of adverse transitions (HR 1.30, CI 1.27-1.35), relative to matched controls (n = 16.377). The effect of concussion differed depending on health and socioeconomic characteristics. Notably, individuals between 30-39 years (HR 0.83, CI 0.79-0.87), individuals with high-income (200.000-300.000 DKK) (HR 0.83, CI 0.80-0.87), and wage earners with management experience (HR 0.60, CI 0.44-0.81) had a markedly lower incidence of favourable transitions compared to controls. Additionally, individuals with high income also had a higher incidence of adverse transitions (HR 1.46, CI 1.34-1.58) compared to controls.

CONCLUSIONS

Concussion was associated with enhanced risk of adverse transitions between labour market states and lower occurrence of favourable transitions, indicating work disability, potentially due to persistent post-concussive symptoms. Some age groups, individuals with high income, and employees with management experience may be more affected.

Understanding the Sociocognitive Determinants Underlying Intentions to Exercise for Postconcussion Symptom Relief: An Application of the Theory of Planned Behavior

CONTEXT

This study investigated individual sociocognitive factors from the theory of planned behavior and their relationship to exercise for postconcussion recovery.

DESIGN AND METHODS

Four hundred and fifty-nine Australian adults, two-thirds of whom had no concussion history (66%), completed an online survey of their beliefs and attitudes toward exercise for postconcussion recovery. Secondary questions evaluated program design features that could affect engagement (eg, session frequency).

RESULTS

Structured equation modeling found that subjective norms were the strongest significant predictor of intention to participate in exercise for postconcussion recovery. Perceived behavioral control was also a significant predictor of intention to participate but to a lesser extent. Attitude did not predict participation intention. The design features identified as key were personalization and being supervised during the program.

CONCLUSIONS

This study found that people's intention to participate in a program of exercise postconcussion recovery is shaped by individual psychological factors and identified program design features that could be adjusted for increased engagement. Program success could be maximized through strategies such as supporting individuals to have a stronger sense of control over their participation through the choice of session timing or frequency and harnessing the influence of significant others via supportive messaging from key professionals.

Vision as a piece of the head trauma puzzle

Approximately half of the brain's circuits are involved in vision and control of eye movements. Therefore, visual dysfunction is a common symptom of concussion, the mildest form of traumatic brain injury (TBI). Photosensitivity, vergence dysfunction, saccadic abnormalities, and distortions in visual perception have been reported as vision-related symptoms following concussion. Impaired visual function has also been reported in populations with a lifetime history of TBI. Consequently, vision-based tools have been developed to detect and diagnose concussion in the acute setting, and characterize visual and cognitive function in those with a lifetime history of TBI. Rapid automatized naming (RAN) tasks have provided widely accessible and quantitative measures of visual-cognitive function. Laboratory-based eye tracking approaches demonstrate promise in measuring visual function and validating results from RAN tasks in patients with concussion. Optical coherence tomography (OCT) has detected neurodegeneration in patients with Alzheimer's disease and multiple sclerosis and may provide critical insight into chronic conditions related to TBI, such as traumatic encephalopathy syndrome. Here, we review the literature and discuss the future directions of vision-based assessments of concussion and conditions related to TBI.

Post-Traumatic Craniocervical Disorders From a Postural Control Perspective: A Narrative Review

Mild traumatic brain injury (mTBI) and whiplash injury (WI) may lead to long-term disabling consequences known as post-concussive syndrome (PCS) and whiplash-associated disorders (WADs). PCS and WAD patients commonly complain of conditions encompassing dizziness, vertigo, headache, neck pain, visual complaints, anxiety, and neurocognitive dysfunctions. A proper medical work-up is a priority in order to rule out any acute treatable consequences. However investigations may remain poorly conclusive. Gathered in the head and neck structures, the ocular sensorimotor, the vestibular, and the cervical proprioceptive systems, all involved in postural control, may be damaged by mTBI or WI. Their dysfunctions are associated with a wide range of functional disorders including symptoms reported by PCS and WAD patients. In addition, the stomatognathic system needs to be specifically assessed particularly when associated to WI. Evidence for considering the post-traumatic impairment of these systems in PCS and WAD-related symptoms is still lacking but seems promising. Furthermore, few studies have considered the assessment and/or treatment of these widely interconnected systems from a comprehensive perspective. We argue that further research focusing on consequences of mTBI and WI on the systems involved in the postural control are necessary in order to bring new perspective of treatment.

Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Mild Traumatic Brain Injury: Approved by ACEP Board of Directors, February 1, 2023 Clinical Policy Endorsed by the Emergency Nurses Association (April 5, 2023)

This 2023 Clinical Policy from the American College of Emergency Physicians is an update of the 2008 “Clinical Policy: Neuroimaging and Decisionmaking in Adult Mild Traumatic Brain Injury in the Acute Setting.” A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following questions: 1) In the adult emergency department patient presenting with minor head injury, are there clinical decision tools to identify patients who do not require a head computed tomography? 2) In the adult emergency department patient presenting with minor head injury, a normal baseline neurologic examination, and taking an anticoagulant or antiplatelet medication, is discharge safe after a single head computed tomography? and 3) In the adult emergency department patient diagnosed with mild traumatic brain injury or concussion, are there clinical decision tools or factors to identify patients requiring follow-up care for postconcussive syndrome or to identify patients with delayed sequelae after emergency department discharge? Evidence was graded and recommendations were made based on the strength of the available data. Widespread and consistent implementation of evidence-based clinical recommendations is warranted to improve patient care.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Intimate Partner Violence-Related Brain Injury Among Colombian Women

OBJECTIVE

The aim of this study was to assess the prevalence of brain injury (BI) and its relationship to cognitive and psychological outcomes in women survivors of intimate partner violence (IPV) in Colombia, South America.

SETTING

Women's shelters and organizations in Barranquilla, Colombia.

PARTICIPANTS

Seventy women from the city of Barranquilla, Colombia, who experienced any form of IPV.

DESIGN

Cross-sectional, retrospective.

MAIN MEASURES

Participants were administered the computerized EMBRACED neuropsychological battery to assess learning, working and long-term memory, cognitive flexibility, and processing speed. Participants also completed measures of psychological symptoms. Partner violence severity was assessed with a semistructured interview for survivors of domestic violence. Presence and severity of IPV-related BI were assessed using the Brain Injury Severity Assessment (BISA).

RESULTS

Thirty-one percent of women sustained at least one BI during an abusive relationship, and 10% sustained repetitive BIs. Furthermore, BI was negatively associated with measures of long-term and working memory, cognitive flexibility, as well as a trending ( P = .05) positive association with depression. With the exception of the relationship between BI and cognitive flexibility, which was substantially reduced and no longer significant, all of these relationships were nearly identical in strength when controlling for abuse severity, socioeconomic status, and educational level.

CONCLUSION

These data are the first to specifically examine IPV-related BI in relation to cognitive and psychological functioning in a sample of Colombian women. These data add cross-cultural knowledge to the limited work in this area that has largely focused on women in North America.

Prevalence and risk factors for anxiety and depression among community dwelling patients with cervical spondylosis during the COVID-19 pandemic

Background

The emergence of COVID-19 and its unfavorable consequences lead to disease fear and other related mental health problems for individuals worldwide. This study aimed to analyze the prevalence and relevant factors of anxiety and depression among community dwelling cervical spondylosis (CS) patients, and to explore the relationship between fear of COVID-19 and anxiety and depression, so as to provide scientific basis for improving their mental health.

Methods

A community-based cross-sectional study was conducted among a cohort of 556 CS patients by using convenient sampling. These participants were asked to complete a demographic questionnaire, the Hospital Anxiety and Depression Scale (HADS), and the Fear of COVID-19 Scale (FCV-19S). The Chi-square test was used to determine the differences among categorical variables. Binary stepwise logistic regression was used to determine predictors of anxiety and depression.

Results

The median HADS-A score was 5 (interquartile interval 2-7), and the median HADS-D score was 4 (interquartile interval 2-8). In this study, the prevalence of anxiety and depression was 25.0% and 26.6%, respectively. Gender and comorbid chronic diseases were predictors of depressive symptoms. In addition, fear of COVID-19 was related to depression and anxiety among community dwelling CS patients.

Conclusion

Approximately one quarter of community dwelling CS patients were suffering depression or anxiety. Our findings could provide a basis for the development of psychological crisis intervention strategies for CS patients under public health emergencies in the future.

More Physical Activity Is Correlated With Reduction in Kinesiophobia for Adolescents With Persistent Symptoms After Concussion

CONTEXT

The relationship between physical activity (PA) and fear of pain with movement (ie, kinesiophobia) during concussion recovery is unknown. Kinesiophobia may limit PA, while PA after concussion may reduce kinesiophobia. Our purpose was to examine the correlation between PA and self-reported kinesiophobia during concussion recovery for adolescents with and without persistent symptoms.

DESIGN

Prospective cohort study of children ages 10-18 years within 14 days of concussion.

METHODS

Participants rated kinesiophobia using the Tampa Scale of Kinesiophobia (TSK) at initial (≤14 d postconcussion) and return to play (RTP) assessments, and wore activity monitors between assessments. Our primary outcome was TSK score change from initial to RTP assessments. We grouped participants based on whether they experienced persistent symptoms (symptoms ≥28 days) or not (symptoms <28 days) and calculated correlation coefficients (Pearson r for normally distributed and Spearman rho for nonnormally distributed variables) between PA variables and TSK change scores.

RESULTS

Among the 41 participants enrolled, 44% developed persistent symptoms (n = 18; age = 14.5 [2.0] y; 50% female; symptom duration = 57.3 [6.2] d; RTP = 66.8 [6.4] d) and 56% did not (n = 23; age = 14.9 [1.8] y; 48% female; symptom duration = 15.2 [1.5] d; RTP = 21.7 [1.9] d). For the persistent symptoms group, greater TSK change scores (mean = -2.5 [5.7] point change) were significantly and moderately correlated with higher daily step count (r = -.60, P = .008) and exercise frequency (r = -.63, P = .005), but were not correlated with exercise duration (ρ = -.12, P = .65). Among the no persistent symptoms group, TSK change scores (mean = -6.0 [5.0] point change) were not correlated with step count (r = -.18, P = .41) or exercise duration (ρ = .10, P = .67), and the correlation with frequency was low and not significant (r = -.34, P = .12).

CONCLUSIONS

Regular PA during concussion recovery, regardless of duration or intensity, may help reduce kinesiophobia for those experiencing persistent symptoms.

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

BACKGROUND AND PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Depressive Symptoms in Individuals With Persistent Postconcussion Symptoms: A Systematic Review and Meta-Analysis

IMPORTANCE

Approximately 15% to 30% of individuals with a history of concussion present with persistent postconcussion symptoms (PPCS). Individuals with PPCS are at greater risk of experiencing depressive symptoms.

OBJECTIVE

To synthesize the association between depressive symptoms and PPCS in children, adolescents, and adults via meta-analysis and to investigate potential moderators of that association.

DATA SOURCES

Systematic search of Ovid Medline, CINAHL, PsycInfo, and Embase from 1995 to January 2022 was performed. Additionally, references from included studies were hand-searched to ensure relevant articles were captured in the search.

STUDY SELECTION

Studies that involved participants who experienced PPCS and quantified depressive symptoms were included. The definition of PPCS was limited to physician-diagnosed or self-reported concussion, with symptoms lasting for a minimum of 4 weeks postinjury. Two authors independently screened all articles to determine study eligibility.

DATA EXTRACTION AND SYNTHESIS

Study characteristics were extracted independently by 2 trained investigators. Study data were meta-analyzed using a random-effects meta-analysis.

EXPOSURE

PPCS.

MAIN OUTCOMES AND MEASURES

The the primary outcome was depressive symptoms.

RESULTS

Data were extracted from 18 studies with a total of 9101 participants. Of the 18 studies, all were cohort studies, and 13 (72%) comprised adult populations. The mean (SD) time since concussion was 21.3 (18.7) weeks. After accounting for potential publication bias, the random-effects meta-analysis found a significant positive association between PPCS and depressive symptoms, (odds ratio, 4.56; 95% CI, 2.82-7.37; P < .001). There were no significant moderators, likely due to the small number of studies included.

CONCLUSIONS AND RELEVANCE

In this meta-analysis, experiencing PPCS was associated with a higher risk of experiencing depressive symptoms. There are several important clinical and health policy implications of the findings. Most notably, the development of strategies for effective prevention and earlier intervention to optimize mental health recovery following a concussion should be supported.

MICK (Mobile Integrated Cognitive Kit) app: Feasibility of an accessible tablet-based rapid picture and number naming task for concussion assessment in a division 1 college football cohort

Although visual symptoms are common following concussion, quantitative measures of visual function are missing from concussion evaluation protocols on the athletic sideline. For the past half century, rapid automatized naming (RAN) tasks have demonstrated promise as quantitative neuro-visual assessment tools in the setting of head trauma and other disorders but have been previously limited in accessibility and scalability. The Mobile Interactive Cognitive Kit (MICK) App is a digital RAN test that can be downloaded on most mobile devices and can therefore provide a quantitative measure of visual function anywhere, including the athletic sideline. This investigation examined the feasibility of MICK App administration in a cohort of Division 1 college football players. Participants (n = 82) from a National Collegiate Athletic Association (NCAA) Division 1 football team underwent baseline testing on the MICK app. Total completion times of RAN tests on the MICK app were recorded; magnitudes of best time scores and between-trial learning effects were determined by paired t-test. Consistent with most timed performance measures, there were significant learning effects between the two baseline trials for both RAN tasks on the MICK app: Mobile Universal Lexicon Evaluation System (MULES) (p < 0.001, paired t-test, mean improvement 13.3 s) and the Staggered Uneven Number (SUN) (p < 0.001, mean improvement 3.3 s). This study demonstrated that the MICK App can be feasibly administered in the setting of pre-season baseline testing in a Division I environment. These data provide a foundation for post-injury sideline testing that will include comparison to baseline in the setting of concussion.

Adolescents with a concussion have altered brain network functional connectivity one month following injury when compared to adolescents with orthopedic injuries

Concussion is a mild traumatic brain injury (mTBI) with increasing prevalence among children and adolescents. Functional connectivity (FC) within and between the default mode network (DMN), central executive network (CEN) and salience network (SN) has been shown to be altered post-concussion. Few studies have investigated connectivity within and between these 3 networks following a pediatric concussion. The present study explored whether within and between-network FC differs between a pediatric concussion and orthopedic injury (OI) group aged 10-18. Participants underwent a resting-state functional magnetic resonance imaging (rs-fMRI) scan at 4 weeks post-injury. One-way ANCOVA analyses were conducted between groups with the seed-based FC of the 3 networks. A total of 55 concussion and 27 OI participants were included in the analyses. Increased within-network FC of the CEN and decreased between-network FC of the DMN-CEN was found in the concussion group when compared to the OI group. Secondary analyses using spherical SN regions of interest revealed increased within-network FC of the SN and increased between-network FC of the DMN-SN and CEN-SN in the concussion group when compared to the OI group. This study identified differential connectivity patterns following a pediatric concussion as compared to an OI 4 weeks post-injury. These differences indicate potential adaptive brain mechanisms that may provide insight into recovery trajectories and appropriate timing of treatment within the first month following a concussion.

Neurotrauma clinicians’ perspectives on the contextual challenges associated with traumatic brain injury follow up in low-income and middle-income countries: A reflexive thematic analysis

Background

Traumatic brain injury (TBI) is a major global health issue, but low- and middle-income countries (LMICs) face the greatest burden. Significant differences in neurotrauma outcomes are recognised between LMICs and high-income countries. However, outcome data is not consistently nor reliably recorded in either setting, thus the true burden of TBI cannot be accurately quantified.

Objective

To explore the specific contextual challenges of, and possible solutions to improve, long-term follow-up following TBI in low-resource settings.

Methods

A cross-sectional, pragmatic qualitative study, that considered knowledge subjective and reality multiple (i.e. situated within the naturalistic paradigm). Data collection utilised semi-structured interviews, by videoconference and asynchronous e-mail. Data were analysed using Braun and Clarke’s six-stage Reflexive Thematic Analysis.

Results

18 neurosurgeons from 13 countries participated in this study, and data analysis gave rise to five themes: Clinical Context: What must we understand?; Perspectives and Definitions: What are we talking about?; Ownership and Beneficiaries: Why do we do it?; Lost to Follow-up: Who misses out and why?; Processes and Procedures: What do we do, or what might we do?

Conclusion

The collection of long-term outcome data plays an imperative role in reducing the global burden of neurotrauma. Therefore, this was an exploratory study that examined the contextual challenges associated with long-term follow-up in LMICs. Where technology can contribute to improved neurotrauma surveillance and remote assessment, these must be implemented in a manner that improves patient outcomes, reduces clinical burden on physicians, and does not surpass the comprehension, capabilities, or financial means of the end user. Future research is recommended to investigate patient and family perspectives, the impact on clinical care teams, and the full economic implications of new technologies for follow-up.

Sex and gender differences in mild traumatic brain injury/concussion

The high incidence of concussions/mild traumatic brain injury and the significant number of people with persisting concussion symptoms as well as the concern for delayed, neurodegenerative effects of concussions makes them a major public health concern. There is much to learn on concussions with respect to pathophysiology as well as vulnerability and resiliency factors. The heterogeneity in outcome after a concussion warrants a more personalized approach to better understand the biological and psychosocial factors that may affect outcome. In this chapter we address biological sex and gender as they impact different aspects of concussion including incidence, risk factors and outcome. As well, this chapter will provide a more fulsome overview of intimate partner violence, an often-overlooked cause of concussion in women. Applying the sex and gender lens to concussion/mild traumatic brain injury is imperative for discovery of its pathophysiology and moving closer to treatments.

Depression, Anxiety, Stress, and Their Associations With Quality of Life in a Nationwide Sample of Psychiatrists in China During the COVID-19 Pandemic

Objectives

The COVID-19 pandemic has negatively affected wellbeing. However, the impact on the mental health status of Chinese psychiatrists and their relationship with quality of life (QOL) has not been examined.

Methods

This was a national cross-sectional survey performed between January 11 and March 15, 2021. Demographic and work-related data were collected anonymously using an online questionnaire. Common mental health symptoms and QOL were assessed using the Depression Anxiety Stress Scale-Chinese version and the World Health Organization Quality of Life Schedule-Brief, respectively.

Results

A total of 3,783 psychiatrists completed this questionnaire. The prevalence of depressive, anxious, and stress symptoms were 26.7% (95%CI = 25.3-28.1%), 24.1% (95%CI = 22.8-25.5%), and 11.6% (95%CI = 10-12%), respectively. Moreover, 11.1% of the participants endorsed both depressive and anxious symptoms, and 8% endorsed symptoms in all three domains. Binary logistic regression showed that aged 30-39 years (OR = 1.5, P = 0.03), male gender (OR = 1.2, P = 0.04), single (OR = 1.44, P = 0.01), and having a negative perception of the COVID-19 on healthcare (OR = 2.34, P <0.001) were factors associated with higher levels of depressive symptoms. Participants who were divorced and widowed (OR = 1.56, P = 0.03), worked more than 4 night shifts/month (OR = 1.33, P<0.001) and/or longer working years (OR = 1.71, P < 0.001), and had a negative perceived impact of the COVID-19 on healthcare (OR = 2.05, P < 0.001) were more inclined to experience anxious symptoms. In addition, psychiatrists with high QOL scores had lower odds of experiencing depressive, anxious, and stress symptoms (all P < 0.001). Multivariate analysis showed that the presence of each of the three types of mental health symptoms was independently associated with lower QOL (all P < 0.05). In addition, the depression × anxious × stress interaction was significantly correlated with lower QOL (P < 0.05).

Conclusion

Approximately one-fourth of psychiatrists in China experienced depressive and anxious symptoms during the COVID-19 pandemic, and more than one-tenth reported stress. Mental health symptoms were significant contributors to lower QOL. The psychological wellbeing of psychiatrists during the pandemic requires more attention, and interventions are needed to improve the psychological wellbeing and QOL of physicians who care for individuals with mental disorders.

Sports- and physical activity-related concussion and mental health among adolescents: Findings from the 2017 and 2019 Youth Risk Behavior Survey

This study examined the association between self-reported sports- or physical activity-related concussion and symptoms of depression and suicidal behaviors (suicidal ideation, having a suicide plan, and suicide attempts). This study used data from the 2017 and 2019 Youth Risk Behavior Survey (YRBS), a biennial, school-based, nationally representative survey of U.S. students in grade levels 9 to 12 (N = 14,496). Multivariate logistical regression models assessed the association between self-reported sports-or physical activity-related concussions and suicidal behaviors among students, controlling for a range of demographic and psychosocial variables. Altogether, 13.6% of students reported a sports-or physical activity related concussion in the past 12 months. Among youth, sports-or physical activity related concussions were significantly associated with greater odds of symptoms of depression, suicidal ideation, making a suicide plan, and suicide attempts compared to other youth who did not experience sports- or physical activity-related concussion. Findings highlight increased risk for adverse mental health outcomes among students with sports-or physical activity related concussions. Providing resources for students to engage in physical activity and sports teams may help prevent the onset of depression and suicidal behaviors; however, resources must also be available to monitor any concussions related to these activities to provide support for student emotional well-being.

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

Objective:

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

Method

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

Results

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

Discussion

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

Intersections of Sex Work, Mental Ill-Health, IPV and Other Violence Experienced by Female Sex Workers: Findings from a Cross-Sectional Community-Centric National Study in South Africa

Female sex workers (FSWs) are at increased risk of mental health problems, including mood disorders and substance abuse, and we need to understand the origins of these to treat and prevent them, and particularly understand how the context in which they sell sex impacts their mental health. We conducted a multi-stage, community-centric, cross-sectional survey of 3005 FSWs linked to SW programmes in twelve sites across all nine provinces of South Africa. We interviewed adult women who had sold sex in the preceding six months, who were recruited via SW networks. We found that FSWs have very poor mental health as 52.7% had depression and 53.6% has post-traumatic stress disorder (PTSD). The structural equation model showed direct pathways from childhood trauma and having HIV+ status to mental ill-health. Indirect pathways were mediated by food insecurity, controlling partners, non-partner rape, harmful alcohol use, substance use to cope with SW, indicators of the circumstances of SW, i.e., selling location (on streets, in taverns and brothels), frequency of selling and experiencing SW stigma. All paths from childhood trauma had final common pathways from exposure to gender-based violence (non-partner rape or intimate partner violence) to mental ill-health, except for one that was mediated by food insecurity. Thus, FSWs’ poor mental health risk was often mediated by their work location and vulnerability to violence, substance abuse and stigma. The potential contribution of legal reform to mitigate the risks of violence and mental ill-health are inescapable. Treatment of mental ill-health and substance abuse should be an essential element of FSW programmes.

Factors Associated with Quality of Life in Adults with Persistent Post-Concussion Symptoms

OBJECTIVE

To assess demographic, clinical, and injury characteristics associated with health-related quality of life (HRQOL) in adults with persistent post-concussion symptoms (PPCS).

METHODS

Adults with PPCS presenting to a specialized brain injury clinic completed demographic, injury, and clinical outcome questionnaires at the initial clinic assessment. Clinical outcome measures were collected including the Rivermead Post-Concussion Symptoms Questionnaire (RPQ), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder Scale-7 (GAD-7), and the Fatigue Severity Scale (FSS). HRQOL was measured using the Quality of Life after Brain Injury (QOLIBRI) questionnaire. Stepwise hierarchical multiple regression analysis adjusting for age, sex, and months since injury was used to determine associations between quality of life and clinical outcome measures.

RESULTS

Overall, 125 participants were included. The PHQ-9, FSS, and GAD-7 were significant predictors of QOLIBRI scores (R2 = 0.481, p < .001), indicating that participants with higher levels of depressive symptoms, fatigue, and anxiety reported poorer HRQOL. The PHQ-9 score was the strongest predictor, accounting for 42.0% of the variance in QOLIBRI scores. No demographic or injury characteristics significantly predicted QOLIBRI scores. There was a high prevalence of depressive symptoms with 72.8% of participants having PHQ-9 scores ≥ 10.

CONCLUSION

Among patients with PPCS, mental health and fatigue are important contributors to HRQOL. As there is a high burden of mood disorders and fatigue in this population, targeted treatments for these concerns may impact the quality of life.