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Rytter HM, Hjorthøj C, Graff HJ, Eplov LF, Nordentoft M, Benros ME, Erlangsen A, Madsen T. Traumatic brain injury and long-term associations with work, divorce and academic achievement. Prev Med 2024; 185:108062. [PMID: 38972606 DOI: 10.1016/j.ypmed.2024.108062] [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] [Received: 03/08/2024] [Revised: 07/02/2024] [Accepted: 07/04/2024] [Indexed: 07/09/2024]
Abstract
OBJECTIVE Traumatic brain injuries (TBI), irrespective of severity, may have long-term social implications. This study explores the relationships between TBI severity and outcomes related to work stability, divorce, and academic achievement. METHODS Using a Danish nationwide sample of persons with and without TBI, we employed case-control and longitudinal cohort designs. The case-control design utilized individuals aged 18 to 60 years and examined work stability. Each case, employed at time of TBI, was compared with 10 matched controls. The cohort design utilized individuals alive from 1980 to 2016 with and without TBI and assessed the likelihood of 1) divorce and 2) higher-level education. TBI exposures included concussion, skull fractures, or confirmed TBI. RESULTS TBI cases exhibited higher odds ratios (OR) for work instability at all follow-ups compared to controls. Increased TBI severity was associated with a higher risk of work instability at 2-year follow-up (concussion: OR = 1.83; skull fracture: OR = 2.22; confirmed TBI: OR = 4.55), and with a higher risk of not working at 10-year follow-up (confirmed TBI: OR = 2.82; concussion: OR = 1.63). The divorce incidence rate ratio (IRR) was elevated in individuals with TBI (males: IRR = 1.52; females: IRR = 1.48) compared to those without TBI. Individuals with childhood TBI had reduced chances of attaining high school degree or higher (males: IRR = 0.79; females: IRR = 0.85) compared to those without TBI. CONCLUSION TBI is associated with an increased long-term risk of social consequences, including work instability, divorce, and diminished chances of higher education, even in cases with concussion.
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Affiliation(s)
- Hana Malá Rytter
- The Danish Concussion Center, Copenhagen, Denmark; Department of Psychology, University of Copenhagen, Copenhagen, Denmark; University Hospital Bispebjerg - Frederiksberg, Department of Neurology, Copenhagen, Denmark.
| | - Carsten Hjorthøj
- CORE - Copenhagen Research Center for Mental Health, Mental Health Center Copenhagen, Mental Health Services in the Capital Region, Copenhagen, Denmark; Department of Public Health, Section of Epidemiology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Heidi Jeannet Graff
- The Danish Concussion Center, Copenhagen, Denmark; Psychiatric Center Ballerup, Mental Health Service of the Capital Region of Denmark, Center for Eating and Feeding Disorders Research, Denmark.
| | - Lene Falgaard Eplov
- CORE - Copenhagen Research Center for Mental Health, Mental Health Center Copenhagen, Mental Health Services in the Capital Region, Copenhagen, Denmark.
| | - Merete Nordentoft
- CORE - Copenhagen Research Center for Mental Health, Mental Health Center Copenhagen, Mental Health Services in the Capital Region, Copenhagen, Denmark.
| | - Michael E Benros
- CORE - Copenhagen Research Center for Mental Health, Mental Health Center Copenhagen, Mental Health Services in the Capital Region, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Annette Erlangsen
- CORE - Copenhagen Research Center for Mental Health, Mental Health Center Copenhagen, Mental Health Services in the Capital Region, Copenhagen, Denmark; Danish Research Institute for Suicide Prevention, Mental Health Center Copenhagen, Copenhagen, Denmark; Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Center of Mental Health Research, Australian National University, Australia.
| | - Trine Madsen
- CORE - Copenhagen Research Center for Mental Health, Mental Health Center Copenhagen, Mental Health Services in the Capital Region, Copenhagen, Denmark; Department of Public Health, Section of Epidemiology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Danish Research Institute for Suicide Prevention, Mental Health Center Copenhagen, Copenhagen, Denmark.
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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 2024:1-10. [PMID: 38828860 DOI: 10.1080/02699052.2024.2361620] [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: 07/02/2023] [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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Bagg MK, Hicks AJ, Hellewell SC, Ponsford JL, Lannin NA, O'Brien TJ, Cameron PA, Cooper DJ, Rushworth N, Gabbe BJ, Fitzgerald M. The Australian Traumatic Brain Injury Initiative: Statement of Working Principles and Rapid Review of Methods to Define Data Dictionaries for Neurological Conditions. Neurotrauma Rep 2024; 5:424-447. [PMID: 38660461 PMCID: PMC11040195 DOI: 10.1089/neur.2023.0116] [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] [Indexed: 04/26/2024] Open
Abstract
The Australian Traumatic Brain Injury Initiative (AUS-TBI) aims to develop a health informatics approach to collect data predictive of outcomes for persons with moderate-severe TBI across Australia. Central to this approach is a data dictionary; however, no systematic reviews of methods to define and develop data dictionaries exist to-date. This rapid systematic review aimed to identify and characterize methods for designing data dictionaries to collect outcomes or variables in persons with neurological conditions. Database searches were conducted from inception through October 2021. Records were screened in two stages against set criteria to identify methods to define data dictionaries for neurological conditions (International Classification of Diseases, 11th Revision: 08, 22, and 23). Standardized data were extracted. Processes were checked at each stage by independent review of a random 25% of records. Consensus was reached through discussion where necessary. Thirty-nine initiatives were identified across 29 neurological conditions. No single established or recommended method for defining a data dictionary was identified. Nine initiatives conducted systematic reviews to collate information before implementing a consensus process. Thirty-seven initiatives consulted with end-users. Methods of consultation were "roundtable" discussion (n = 30); with facilitation (n = 16); that was iterative (n = 27); and frequently conducted in-person (n = 27). Researcher stakeholders were involved in all initiatives and clinicians in 25. Importantly, only six initiatives involved persons with lived experience of TBI and four involved carers. Methods for defining data dictionaries were variable and reporting is sparse. Our findings are instructive for AUS-TBI and can be used to further development of methods for defining data dictionaries.
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Affiliation(s)
- Matthew K. Bagg
- Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, Western Australia, Australia
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, New South Wales, Australia
- School of Health Sciences, University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Amelia J. Hicks
- School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Victoria, Australia
| | - Sarah C. Hellewell
- Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, Western Australia, Australia
| | - Jennie L. Ponsford
- School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Victoria, Australia
| | - Natasha A. Lannin
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Alfred Health, Melbourne, Victoria, Australia
| | - Terence J. O'Brien
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Peter A. Cameron
- National Trauma Research Institute, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - D. Jamie Cooper
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Nick Rushworth
- Brain Injury Australia, Sydney, New South Wales, Australia
| | - Belinda J. Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Health Data Research UK, Swansea University Medical School, Swansea University, Singleton Park, United Kingdom
| | - Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, Western Australia, Australia
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Næss-Schmidt ET, Thastum MM, Stabel HH, Odgaard L, Pedersen AR, Rask CU, Silverberg ND, Schröder A, Nielsen JF. Interdisciplinary intervention (GAIN) for adults with post-concussion symptoms: a study protocol for a stepped-wedge cluster randomised trial. Trials 2022; 23:613. [PMID: 35906645 PMCID: PMC9338593 DOI: 10.1186/s13063-022-06572-7] [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: 05/29/2022] [Accepted: 07/20/2022] [Indexed: 12/02/2022] Open
Abstract
Background Persistent post-concussion symptoms (PCS) are associated with prolonged disability, reduced health-related quality of life and reduced workability. At present, no strong evidence for treatments for people with persistent PCS exists. Our research group developed a novel intervention, “Get going After concussIoN (GAIN)”, that incorporates multiple evidence-based strategies including prescribed exercise, cognitive behavioural therapy, and gradual return to activity advice. In a previous randomised trial, GAIN provided in a hospital setting was effective in reducing symptoms in 15–30-year-olds with PCS 2–6 months post-injury. In the current study, we describe the protocol for a trial designed to test the effectiveness of GAIN in a larger municipality setting. Additionally, we test the intervention within a broader age group and evaluate a broader range of outcomes. The primary hypothesis is that participants allocated to enhanced usual care plus GAIN report a higher reduction in PCS 3 months post-intervention compared to participants allocated to enhanced usual care only. Methods The study is a stepped-wedge cluster-randomised trial with five clusters. The 8-week interdisciplinary GAIN program will be rolled out to clusters in 3-month intervals. Power calculation yield at least 180 participants to be enrolled. Primary outcome is mean change in PCS measured by the Rivermead Post-Concussion Symptoms Questionnaire from enrolment to 3 months after end of treatment. Secondary outcomes include participation in and satisfaction with everyday activities, labour market attachment and other behavioural measures. Self-reported outcomes are measured at baseline, by end of treatment and at 3, 6, and 18 months after end of treatment. Registry-based outcomes are measured up to 36 months after concussion. Discussion The trial will provide important information concerning the effectiveness of the GAIN intervention in a municipality setting. Furthermore, it will provide knowledge of possible barriers and facilitators that may be relevant for future implementation of GAIN in different settings. Trial registration The current GAIN trial is registered in ClinicalTrials.gov (study identifier: NCT04798885) on 20 October 2020. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06572-7.
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Affiliation(s)
- Erhard Trillingsgaard Næss-Schmidt
- Hammel Neurorehabilitation Centre and University Research Clinic, Health, Aarhus University, Aarhus, Denmark. .,Department of Clinical Medicine, AU, Aarhus, Denmark.
| | - Mille Møller Thastum
- Hammel Neurorehabilitation Centre and University Research Clinic, Health, Aarhus University, Aarhus, Denmark
| | - Henriette Holm Stabel
- Hammel Neurorehabilitation Centre and University Research Clinic, Health, Aarhus University, Aarhus, Denmark
| | - Lene Odgaard
- Hammel Neurorehabilitation Centre and University Research Clinic, Health, Aarhus University, Aarhus, Denmark
| | - Asger Roer Pedersen
- Hammel Neurorehabilitation Centre and University Research Clinic, Health, Aarhus University, Aarhus, Denmark.,Department of Clinical Medicine, AU, Aarhus, Denmark
| | - Charlotte Ulrikka Rask
- Department of Clinical Medicine, AU, Aarhus, Denmark.,Department of Child and Adolescent Psychiatry, Psychiatry, Aarhus University Hospital, Aarhus, Denmark
| | - Noah D Silverberg
- Department of Psychology, University of British Columbia, Vancouver, Canada
| | - Andreas Schröder
- Research Clinic for Functional Disorders, Aarhus University Hospital, Aarhus, Denmark
| | - Jørgen Feldbæk Nielsen
- Hammel Neurorehabilitation Centre and University Research Clinic, Health, Aarhus University, Aarhus, Denmark.,Department of Clinical Medicine, AU, Aarhus, Denmark
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Outlining the Invisible: Experiences and Perspectives Regarding Concussion Recovery, Return-to-Work, and Resource Gaps. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19138204. [PMID: 35805862 PMCID: PMC9266414 DOI: 10.3390/ijerph19138204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/01/2022] [Accepted: 07/01/2022] [Indexed: 02/01/2023]
Abstract
Appropriate supports and accommodations are necessary to ensure full concussion recovery and return-to-work (RTW). This research investigated barriers and facilitators to concussion recovery and RTW, and resource gaps reported by adults with concussion (‘workers’) and workplace and healthcare professionals (‘workplaces’). Semi-structured interviews and focus groups were conducted with workers (n = 31) and workplaces (n = 16) across British Columbia. Data were analyzed using inductive content analysis. Facilitators to workers’ concussion recovery and RTW included treatment, social support, and workplace and lifestyle modifications. To address barriers, both groups recommended: (a) widespread concussion and RTW education and training (b) standardized concussion recovery guidelines; (c) changing attitudes toward concussion; (d) mental health supports; and (e) increasing awareness that every concussion is unique. Findings can inform best practice for concussion recovery and RTW among professionals in workplaces, healthcare, occupational health and safety, and workers’ compensation boards.
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Fitzgerald M, Ponsford J, Lannin NA, O'Brien TJ, Cameron P, Cooper DJ, Rushworth N, Gabbe B. AUS-TBI: The Australian Health Informatics Approach to Predict Outcomes and Monitor Intervention Efficacy after Moderate-to-Severe Traumatic Brain Injury. Neurotrauma Rep 2022; 3:217-223. [PMID: 35919508 PMCID: PMC9279124 DOI: 10.1089/neur.2022.0002] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Predicting and optimizing outcomes after traumatic brain injury (TBI) remains a major challenge because of the breadth of injury characteristics and complexity of brain responses. AUS-TBI is a new Australian Government–funded initiative that aims to improve personalized care and treatment for children and adults who have sustained a TBI. The AUS-TBI team aims to address a number of key knowledge gaps, by designing an approach to bring together data describing psychosocial modulators, social determinants, clinical parameters, imaging data, biomarker profiles, and rehabilitation outcomes in order to assess the influence that they have on long-term outcome. Data management systems will be designed to track a broad range of suitable potential indicators and outcomes, which will be organized to facilitate secure data collection, linkage, storage, curation, management, and analysis. It is believed that these objectives are achievable because of our consortium of highly committed national and international leaders, expert committees, and partner organizations in TBI and health informatics. It is anticipated that the resulting large-scale data resource will facilitate personalization, prediction, and improvement of outcomes post-TBI.
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Affiliation(s)
- Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Curtin University, Nedlands, Western Australia, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, Western Australia, Australia
| | - Jennie Ponsford
- School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
- Monash Epworth Rehabilitation Research Centre–Epworth Healthcare, Richmond, Victoria, Australia
| | - Natasha A. Lannin
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Terence J. O'Brien
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Peter Cameron
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - D. James Cooper
- Australian and New Zealand Intensive Care Research Centre Recovery Program (ANZIC-RC), Monash University, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Nick Rushworth
- Brain Injury Australia, Sydney, New South Wales, Australia
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Sex differences in outcomes from mild traumatic brain injury eight years post-injury. PLoS One 2022; 17:e0269101. [PMID: 35622845 PMCID: PMC9140230 DOI: 10.1371/journal.pone.0269101] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 05/16/2022] [Indexed: 11/19/2022] Open
Abstract
The long-term effects of mild TBI (mTBI) are not well understood, and there is an ongoing debate about whether there are sex differences in outcomes following mTBI. This study examined i) symptom burden and functional outcomes at 8-years post-injury in males and females following mTBI; ii) sex differences in outcomes at 8-years post-injury for those aged <45 years and ≥45 years and; iii) sex differences in outcomes for single and repetitive TBI. Adults (≥16 years at injury) identified as part of a population-based TBI incidence study (BIONIC) who experienced mTBI 8-years ago (N = 151) and a TBI-free sample (N = 151) completed self-report measures of symptoms and symptom burden (Rivermead Post-Concussion Symptom Questionnaire, Hospital Anxiety and Depression Scale, Post-traumatic Stress Disorder Checklist), and functional outcomes (Participation Assessments with Recombined Tools, Work Limitations Questionnaire). The mTBI group reported significantly greater post-concussion symptoms compared to the TBI-free group (F(1,298) = 26.84, p<.01, ηp2 = .08). Females with mTBI were twice as likely to exceed clinical cut-offs for post-concussive (X2 (1)>5.2, p<.05, V>.19) and PTSD symptoms (X2(1) = 6.10, p = .014, V = .20) compared to the other groups, and reported their health had the greatest impact on time-related work demands (F(1,171) = 4.36, p = .04, ηp2 = .03. There was no interaction between sex and age on outcomes. The repetitive mTBI group reported significantly greater post-concussion symptoms (F(1,147) = 9.80, p<.01, ηp2 = .06) compared to the single mTBI group. Twice the proportion of women with repetitive mTBI exceeded the clinical cut-offs for post-concussive (X2(1)>6.90, p<.01, V>.30), anxiety (X2(1)>3.95, p<.05, V>.23) and PTSD symptoms (X2(1)>5.11, p<.02, V>.26) compared with males with repetitive TBI or women with single TBI. Thus, at 8-years post-mTBI, people continued to report a high symptom burden. Women with mTBI, particularly those with a history of repetitive mTBI, had the greatest symptom burden and were most likely to have symptoms of clinical significance. When treating mTBI it is important to assess TBI history, particularly in women. This may help identify those at greatest risk of poor long-term outcomes to direct early treatment and intervention.
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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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