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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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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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3
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Valente JH, Anderson JD, Paolo WF, Sarmiento K, Tomaszewski CA, Haukoos JS, Diercks DB, Diercks DB, Anderson JD, Byyny R, Carpenter CR, Friedman B, Gemme SR, Gerardo CJ, Godwin SA, Hahn SA, Hatten BW, Haukoos JS, Kaji A, Kwok H, Lo BM, Mace SE, Moran M, Promes SB, Shah KH, Shih RD, Silvers SM, Slivinski A, Smith MD, Thiessen MEW, Tomaszewski CA, Trent S, Valente JH, Wall SP, Westafer LM, Yu Y, Cantrill SV, Finnell JT, Schulz T, Vandertulip K. 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). Ann Emerg Med 2023; 81:e63-e105. [PMID: 37085214 PMCID: PMC10617828 DOI: 10.1016/j.annemergmed.2023.01.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2023]
Abstract
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.
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Jobin K, Wang M, du Plessis S, Silverberg ND, Debert CT. The importance of screening for functional neurological disorders in patients with persistent post-concussion symptoms. NeuroRehabilitation 2023; 53:199-208. [PMID: 37638460 DOI: 10.3233/nre-237002] [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: 08/29/2023]
Abstract
BACKGROUND Functional neurological disorder (FND) may commonly co-occur with persistent symptoms following a psychological trauma or physical injury such as concussion. OBJECTIVE To explore the occurrence of FND in a population with persistent post-concussion symptoms (PPCS) and the associations between FND and depression as well as anxiety in participants with PPCS. METHODS Sixty-three individuals with PPCS presenting to a specialized brain injury clinic completed the following questionnaires: screening for somatoform disorder conversion disorder subscale (SOM-CD), Rivermead post-concussion symptom questionnaire (RPQ), patient health questionnaire-9 (PHQ-9), and generalized anxiety disorder questionnaire- 7 (GAD-7). Both multiple linear regression and logistic regression were conducted to evaluate the relationship between questionnaires and adjust for covariates. RESULTS We found that total RPQ score (βˆ= 0.27; 95% CI = [0.16, 0.38]), GAD-7 score (βˆ= 0.71; 95% CI = [0.50, 0.92]) and PHQ-9 score (βˆ= 0.54; 95% CI = [0.32, 0.76]) were positively associated with SOM-CD score individually, after consideration of other covariates. Participants meeting the criteria for severe FND symptoms were 4.87 times more likely to have high PPCS symptom burden (95% CI = [1.57, 22.84]), 8.95 times more likely to have severe anxiety (95% CI = [3.31, 35.03]) and 4.11 times more likely to have severe depression symptom burden (95% CI = [1.77, 11.53]). CONCLUSION The findings of this study indicate an association between FND and post-concussion symptoms as well as an association between FND and symptoms of depression and anxiety in patients with PPCS. Patients with PPCS should be screened for FND to provide a more targeted treatment approach that includes somatic-focused interventions.
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Affiliation(s)
- Kaiden Jobin
- Department of Clinical Neurosciences, Cumming School of Medicine, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Meng Wang
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Sané du Plessis
- Department of Clinical Neurosciences, Cumming School of Medicine, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Noah D Silverberg
- Department of Psychology, University of British Columbia, Vancouver, BC, Canada
| | - Chantel T Debert
- Department of Clinical Neurosciences, Cumming School of Medicine, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
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Toman E, Hodgson S, Riley M, Welbury R, Di Pietro V, Belli A. Concussion in the UK: a contemporary narrative review. Trauma Surg Acute Care Open 2022; 7:e000929. [PMID: 36274785 PMCID: PMC9582316 DOI: 10.1136/tsaco-2022-000929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 09/03/2022] [Indexed: 11/18/2022] Open
Abstract
Concussion has been receiving an increasing amount of media exposure following several high-profile professional sports controversies and multimillion-dollar lawsuits. The potential life-changing sequalae of concussion and the rare, but devasting, second impact syndrome have also gained much attention. Despite this, our knowledge of the pathological processes involved is limited and often extrapolated from research into more severe brain injuries. As there is no objective diagnostic test for concussion. Relying on history and examination only, the diagnosis of concussion has become the rate-limiting step in widening research into the disease. Clinical study protocols therefore frequently exclude the most vulnerable groups of patients such as those with existing cognitive impairment, concurrent intoxication, mental health issues or learning difficulties. This up-to-date narrative review aims to summarize our current concussion knowledge and provides an insight into promising avenues for future research.
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Affiliation(s)
- Emma Toman
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK,Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sam Hodgson
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Max Riley
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Richard Welbury
- School of Dentistry, University of Central Lancashire, Preston, UK
| | - Valentina Di Pietro
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK,NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Antonio Belli
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK,Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK,NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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6
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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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7
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Gozt AK, Hellewell SC, Thorne J, Thomas E, Buhagiar F, Markovic S, Van Houselt A, Ring A, Arendts G, Smedley B, Van Schalkwyk S, Brooks P, Iliff J, Celenza A, Mukherjee A, Xu D, Robinson S, Honeybul S, Cowen G, Licari M, Bynevelt M, Pestell CF, Fatovich D, Fitzgerald M. Predicting outcome following mild traumatic brain injury: protocol for the longitudinal, prospective, observational Concussion Recovery ( CREST) cohort study. BMJ Open 2021; 11:e046460. [PMID: 33986061 PMCID: PMC8126315 DOI: 10.1136/bmjopen-2020-046460] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Mild traumatic brain injury (mTBI) is a complex injury with heterogeneous physical, cognitive, emotional and functional outcomes. Many who sustain mTBI recover within 2 weeks of injury; however, approximately 10%-20% of individuals experience mTBI symptoms beyond this 'typical' recovery timeframe, known as persistent post-concussion symptoms (PPCS). Despite increasing interest in PPCS, uncertainty remains regarding its prevalence in community-based populations and the extent to which poor recovery may be identified using early predictive markers. OBJECTIVE (1) Establish a research dataset of people who have experienced mTBI and document their recovery trajectories; (2) Evaluate a broad range of novel and established prognostic factors for inclusion in a predictive model for PPCS. METHODS AND ANALYSIS The Concussion Recovery Study (CREST) is a prospective, longitudinal observational cohort study conducted in Perth, Western Australia. CREST is recruiting adults aged 18-65 from medical and community-based settings with acute diagnosis of mTBI. CREST will create a state-wide research dataset of mTBI cases, with data being collected in two phases. Phase I collates data on demographics, medical background, lifestyle habits, nature of injury and acute mTBI symptomatology. In Phase II, participants undergo neuropsychological evaluation, exercise tolerance and vestibular/ocular motor screening, MRI, quantitative electroencephalography and blood-based biomarker assessment. Follow-up is conducted via telephone interview at 1, 3, 6 and 12 months after injury. Primary outcome measures are presence of PPCS and quality of life, as measured by the Post-Concussion Symptom Scale and the Quality of Life after Brain Injury questionnaires, respectively. Multivariate modelling will examine the prognostic value of promising factors. ETHICS AND DISSEMINATION Human Research Ethics Committees of Royal Perth Hospital (#RGS0000003024), Curtin University (HRE2019-0209), Ramsay Health Care (#2009) and St John of God Health Care (#1628) have approved this study protocol. Findings will be published in peer-reviewed journals and presented at scientific conferences. TRIAL REGISTRATION NUMBER ACTRN12619001226190.
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Affiliation(s)
- Aleksandra Karolina Gozt
- Curtin Health Innovation Research Institute, Curtin University Faculty of Health Sciences, Bentley, Western Australia, Australia
- Perron Institute of Neurological and Translational Science, Nedlands, Western Australia, Australia
| | - Sarah Claire Hellewell
- Curtin Health Innovation Research Institute, Curtin University Faculty of Health Sciences, Bentley, Western Australia, Australia
| | - Jacinta Thorne
- Curtin Health Innovation Research Institute, Curtin University Faculty of Health Sciences, Bentley, Western Australia, Australia
| | - Elizabeth Thomas
- Centre for Clinical Research Excellence, School of Population Health, Curtin University, Bentley, Western Australia, Australia
- Division of Surgery, Faculty of Health & Medical Sciences, The University of Western Australia, Crawley, Western Australia, Australia
| | - Francesca Buhagiar
- School of Psychological Science, The University of Western Australia, Crawley, Western Australia, Australia
| | - Shaun Markovic
- Australian Alzheimer's Research Foundation, Nedlands, Western Australia, Australia
- The Centre for Healthy Ageing, Health Futures Institute, Murdoch University, Murdoch, Western Australia, Australia
| | - Anoek Van Houselt
- School of Human Sciences, The University of Western Australia, Crawley, Western Australia, Australia
| | - Alexander Ring
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia
- School of Physiotherapy and Exercise Science, Curtin University Faculty of Health Sciences, Bentley, Western Australia, Australia
| | - Glenn Arendts
- Emergency Department, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Nedlands, Western Australia, Australia
| | - Ben Smedley
- Emergency Department, Rockingham General Hospital, Cooloongup, Western Australia, Australia
| | - Sjinene Van Schalkwyk
- Emergency Department, Joondalup Health Campus, Joondalup, Western Australia, Australia
| | - Philip Brooks
- Emergency Department, Saint John of God Midland Public Hospital, Midland, Western Australia, Australia
- School of Medicine, The University of Notre Dame and Curtin Medical School, Curtin University, Perth, Western Australia, Australia
- Curtin Medical School, Curtin University, Bentley, Western Australia, Australia
| | - John Iliff
- Curtin Medical School, Curtin University, Bentley, Western Australia, Australia
- Emergency Department, Saint John of God Hospital Murdoch, Murdoch, Western Australia, Australia
- Emergency Department, Royal Perth Hospital, Perth, Western Australia, Australia
- Royal Flying Doctor Service- Western Operations, Jandakot, Western Australia, Australia
| | - Antonio Celenza
- Emergency Department, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
- Division of Emergency Medicine, School of Medicine, The University of Western Australia, Crawley, Western Australia, Australia
| | - Ashes Mukherjee
- Emergency Department, Armadale Health Service, Mount Nasura, Western Australia, Australia
| | - Dan Xu
- Centre for Clinical Research Excellence, School of Population Health, Curtin University, Bentley, Western Australia, Australia
- The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Suzanne Robinson
- Centre for Clinical Research Excellence, School of Population Health, Curtin University, Bentley, Western Australia, Australia
| | - Stephen Honeybul
- Statewide Director of Neurosurgery, Department of Health Government of Western Australia, Perth, Western Australia, Australia
- Head of Department, Sir Charles Gairdner Hospital, Royal Perth Hospital and Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Gill Cowen
- Curtin Medical School, Curtin University, Bentley, Western Australia, Australia
| | - Melissa Licari
- School of Human Sciences, The University of Western Australia, Crawley, Western Australia, Australia
- Telethon Kids Institute, West Perth, Western Australia, Australia
| | - Michael Bynevelt
- Division of Surgery, School of Medicine, The University of Western Australia, Crawley, Western Australia, Australia
- The Neurological Intervention & Imaging Service of Western Australia at Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Carmela F Pestell
- Curtin Health Innovation Research Institute, Curtin University Faculty of Health Sciences, Bentley, Western Australia, Australia
- School of Psychological Science, The University of Western Australia, Crawley, Western Australia, Australia
| | - Daniel Fatovich
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Nedlands, Western Australia, Australia
- Emergency Medicine, Royal Perth Hospital, The University of Western Australia, Perth, Western Australia, Australia
| | - Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Curtin University Faculty of Health Sciences, Bentley, Western Australia, Australia
- Perron Institute of Neurological and Translational Science, Nedlands, Western Australia, Australia
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Varner C, Thompson C, de Wit K, Borgundvaag B, Houston R, McLeod S. Predictors of persistent concussion symptoms in adults with acute mild traumatic brain injury presenting to the emergency department. CAN J EMERG MED 2021; 23:365-373. [PMID: 33555602 DOI: 10.1007/s43678-020-00076-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 12/23/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To identify risk factors associated with persistent concussion symptoms in adults presenting to the emergency department (ED) with acute mild traumatic brain injury (TBI). METHODS This was a secondary analysis of a randomized controlled trial conducted in three Canadian EDs whereby the intervention had no impact on recovery or healthcare utilization outcomes. Adult (18-64 years) patients with a mild TBI sustained within the preceding 48 h were eligible for enrollment. The primary outcome was the presence of persistent concussion symptoms at 30 days, defined as the presence of ≥ 3 symptoms on the Rivermead Post-concussion Symptoms Questionnaire. RESULTS Of the 241 patients who completed follow-up, median (IQR) age was 33 (25 to 50) years, and 147 (61.0%) were female. At 30 days, 49 (20.3%) had persistent concussion symptoms. Using multivariable logistic regression, headache at ED presentation (OR: 7.7; 95% CI 1.6 to 37.8), being under the influence of drugs or alcohol at the time of injury (OR: 5.9; 95% CI 1.8 to 19.4), the injury occurring via bike or motor vehicle collision (OR: 2.9; 95% CI 1.3 to 6.0), history of anxiety or depression (OR: 2.4; 95% CI 1.2 to 4.9), and numbness or tingling at ED presentation (OR: 2.4; 95% CI 1.1 to 5.2), were found to be independently associated with persistent concussion symptoms at 30 days. CONCLUSIONS Five variables were found to be significant predictors of persistent concussion symptoms. Although mild TBI is mostly a self-limited condition, patients with these risk factors should be considered high risk for developing persistent concussion symptoms and flagged for early outpatient follow-up.
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Affiliation(s)
- Catherine Varner
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada. .,Schwartz/Reisman Emergency Medicine Institute, Toronto, ON, Canada. .,Department of Family and Community Medicine, University of Toronto, 206-600 University Avenue, Toronto, ON, M5G 1X5, Canada. .,Sinai Health System, Toronto, ON, Canada.
| | - Cameron Thompson
- Schwartz/Reisman Emergency Medicine Institute, Toronto, ON, Canada.,Sinai Health System, Toronto, ON, Canada
| | - Kerstin de Wit
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Bjug Borgundvaag
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Schwartz/Reisman Emergency Medicine Institute, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, 206-600 University Avenue, Toronto, ON, M5G 1X5, Canada.,Sinai Health System, Toronto, ON, Canada
| | - Reaves Houston
- Schwartz/Reisman Emergency Medicine Institute, Toronto, ON, Canada
| | - Shelley McLeod
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Schwartz/Reisman Emergency Medicine Institute, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, 206-600 University Avenue, Toronto, ON, M5G 1X5, Canada.,Sinai Health System, Toronto, ON, Canada
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9
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Rickards TA, Cranston CC, McWhorter J. Persistent post-concussive symptoms: A model of predisposing, precipitating, and perpetuating factors. APPLIED NEUROPSYCHOLOGY-ADULT 2020; 29:284-294. [PMID: 32356498 DOI: 10.1080/23279095.2020.1748032] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
While the majority of individuals make full recovery within a short period following mild traumatic brain injury (mTBI), some continue to experience a more chronic course of symptoms termed persistent post-concussive symptoms (PPCS). Previous models and conceptualizations of PPCS have typically not differentiated the time at which factors present across the injury timeline spectrum or have considered a limited array of contributory factors. In the current review, PPCS are examined within the predisposing, precipitating, and perpetuating (PPP) model, which has been applied to explain other syndromes resulting in a clear framework to explain, disseminate, and further research the specified condition. Previous PPCS models are reviewed and integrated into this comprehensive model, as well. To do so, a literature review was completed which included previous PPP models applied to other conditions, other PPCS models, and more recent findings of factors related to PPCS. This new iteration and application of the PPP model more clearly, completely, and validly identifies contributing factors to PPCS. Future prevention, early identification, clearer questions for future research, and treatment of PPCS is possible with clarity provided by this model.
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Affiliation(s)
- Tyler A Rickards
- Division of Medical Psychology, Department of Neurology, LifeBridge Health, Baltimore, MD, USA
| | | | - Jessica McWhorter
- Division of Medical Psychology, Department of Neurology, LifeBridge Health, Baltimore, MD, USA
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10
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Lange RT, Lippa SM, Bailie JM, Wright M, Driscoll A, Sullivan J, Gartner R, Ramin D, Robinson G, Eshera Y, Gillow K, French LM, Brickell TA. Longitudinal trajectories and risk factors for persistent postconcussion symptom reporting following uncomplicated mild traumatic brain injury in U.S. Military service members. Clin Neuropsychol 2020; 34:1134-1155. [DOI: 10.1080/13854046.2020.1746832] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Rael T. Lange
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, MD, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
- University of British Columbia, Vancouver, Canada
| | - Sara M. Lippa
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, MD, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Jason M. Bailie
- Defense and Veterans Brain Injury Center, Naval Hospital Camp Pendleton, CA, USA
| | - Megan Wright
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, MD, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Angela Driscoll
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, MD, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Jamie Sullivan
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, MD, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Rachel Gartner
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, MD, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Daniel Ramin
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, MD, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Gabrielle Robinson
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, MD, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Yasmine Eshera
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, MD, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Kelly Gillow
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, MD, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Louis M. French
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, MD, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Tracey A. Brickell
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, MD, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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11
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Gozt A, Licari M, Halstrom A, Milbourn H, Lydiard S, Black A, Arendts G, Macdonald S, Song S, MacDonald E, Vlaskovsky P, Burrows S, Bynevelt M, Pestell C, Fatovich D, Fitzgerald M. Towards the Development of an Integrative, Evidence-Based Suite of Indicators for the Prediction of Outcome Following Mild Traumatic Brain Injury: Results from a Pilot Study. Brain Sci 2020; 10:brainsci10010023. [PMID: 31906443 PMCID: PMC7017246 DOI: 10.3390/brainsci10010023] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 12/16/2019] [Accepted: 12/30/2019] [Indexed: 12/14/2022] Open
Abstract
Background: Persisting post-concussion symptoms (PPCS) is a complex, multifaceted condition in which individuals continue to experience the symptoms of mild traumatic brain injury (mTBI; concussion) beyond the timeframe that it typically takes to recover. Currently, there is no way of knowing which individuals may develop this condition. Method: Patients presenting to a hospital emergency department (ED) within 48 h of sustaining a mTBI underwent neuropsychological assessment and demographic, injury-related information and blood samples were collected. Concentrations of blood-based biomarkers neuron specific enolase, neurofilament protein-light, and glial fibrillary acidic protein were assessed, and a subset of patients also underwent diffusion tensor–magnetic resonance imaging; both relative to healthy controls. Individuals were classified as having PPCS if they reported a score of 25 or higher on the Rivermead Postconcussion Symptoms Questionnaire at ~28 days post-injury. Univariate exact logistic regression was performed to identify measures that may be predictive of PPCS. Neuroimaging data were examined for differences in fractional anisotropy (FA) and mean diffusivity in regions of interest. Results: Of n = 36 individuals, three (8.33%) were classified as having PPCS. Increased performance on the Repeatable Battery for the Assessment of Neuropsychological Status Update Total Score (OR = 0.81, 95% CI: 0.61–0.95, p = 0.004), Immediate Memory (OR = 0.79, 95% CI: 0.56–0.94, p = 0.001), and Attention (OR = 0.86, 95% CI: 0.71–0.97, p = 0.007) indices, as well as faster completion of the Trails Making Test B (OR = 1.06, 95% CI: 1.00–1.12, p = 0.032) at ED presentation were associated with a statistically significant decreased odds of an individual being classified as having PPCS. There was no significant association between blood-based biomarkers and PPCS in this small sample, although glial fibrillary acidic protein (GFAP) was significantly increased in individuals with mTBI relative to healthy controls. Furthermore, relative to healthy age and sex-matched controls (n = 8), individuals with mTBI (n = 14) had higher levels of FA within the left inferior frontal occipital fasciculus (t (18.06) = −3.01, p = 0.008). Conclusion: Performance on neuropsychological measures may be useful for predicting PPCS, but further investigation is required to elucidate the utility of this and other potential predictors.
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Affiliation(s)
- Aleksandra Gozt
- Curtin Health Innovation Research Institute, Curtin University, Bentley, WA 6102, Australia; (A.G.); (A.B.); (C.P.)
- Perron Institute for Neurological and Translational Science, Nedlands, WA 6009, Australia
| | - Melissa Licari
- Telethon Kids Institute, West Perth, WA 6005, Australia;
| | - Alison Halstrom
- School of Biological Sciences, The University of Western Australia, Crawley, WA 6009, Australia; (A.H.); (H.M.); (S.L.)
| | - Hannah Milbourn
- School of Biological Sciences, The University of Western Australia, Crawley, WA 6009, Australia; (A.H.); (H.M.); (S.L.)
| | - Stephen Lydiard
- School of Biological Sciences, The University of Western Australia, Crawley, WA 6009, Australia; (A.H.); (H.M.); (S.L.)
| | - Anna Black
- Curtin Health Innovation Research Institute, Curtin University, Bentley, WA 6102, Australia; (A.G.); (A.B.); (C.P.)
- Perron Institute for Neurological and Translational Science, Nedlands, WA 6009, Australia
| | - Glenn Arendts
- Emergency Medicine, The University of Western Australia, Crawley, WA 6009, Australia; (G.A.); (S.M.); (D.F.)
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Nedlands, WA 6000, Australia;
| | - Stephen Macdonald
- Emergency Medicine, The University of Western Australia, Crawley, WA 6009, Australia; (G.A.); (S.M.); (D.F.)
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Nedlands, WA 6000, Australia;
- Emergency Department, Royal Perth Hospital, Perth, WA 6000, Australia
| | - Swithin Song
- Radiology Department, Royal Perth Hospital, Perth, WA 6000, Australia;
| | - Ellen MacDonald
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Nedlands, WA 6000, Australia;
- Emergency Department, Royal Perth Hospital, Perth, WA 6000, Australia
| | - Philip Vlaskovsky
- School of Medicine, The University of Western Australia, Crawley, WA 6009, Australia; (P.V.); (S.B.)
| | - Sally Burrows
- School of Medicine, The University of Western Australia, Crawley, WA 6009, Australia; (P.V.); (S.B.)
| | - Michael Bynevelt
- School of Surgery, The University of Western Australia, Crawley, WA 6009, Australia;
- Neurological Intervention and Imaging Service of Western Australia, Sir Charles Gardener Hospital, Nedlands, WA 6009, Australia
| | - Carmela Pestell
- Curtin Health Innovation Research Institute, Curtin University, Bentley, WA 6102, Australia; (A.G.); (A.B.); (C.P.)
- School of Psychological Science, The University of Western Australia, Crawley, WA 6009, Australia
| | - Daniel Fatovich
- Emergency Medicine, The University of Western Australia, Crawley, WA 6009, Australia; (G.A.); (S.M.); (D.F.)
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Nedlands, WA 6000, Australia;
- Emergency Department, Royal Perth Hospital, Perth, WA 6000, Australia
| | - Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Curtin University, Bentley, WA 6102, Australia; (A.G.); (A.B.); (C.P.)
- Perron Institute for Neurological and Translational Science, Nedlands, WA 6009, Australia
- School of Biological Sciences, The University of Western Australia, Crawley, WA 6009, Australia; (A.H.); (H.M.); (S.L.)
- Correspondence: ; Tel.: +61-467-729-300
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12
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Lumba-Brown A, Teramoto M, Bloom OJ, Brody D, Chesnutt J, Clugston JR, Collins M, Gioia G, Kontos A, Lal A, Sills A, Ghajar J. Concussion Guidelines Step 2: Evidence for Subtype Classification. Neurosurgery 2020; 86:2-13. [PMID: 31432081 PMCID: PMC6911735 DOI: 10.1093/neuros/nyz332] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 06/23/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Concussion is a heterogeneous mild traumatic brain injury (mTBI) characterized by a variety of symptoms, clinical presentations, and recovery trajectories. By thematically classifying the most common concussive clinical presentations into concussion subtypes (cognitive, ocular-motor, headache/migraine, vestibular, and anxiety/mood) and associated conditions (cervical strain and sleep disturbance), we derive useful definitions amenable to future targeted treatments. OBJECTIVE To use evidence-based methodology to characterize the 5 concussion subtypes and 2 associated conditions and report their prevalence in acute concussion patients as compared to baseline or controls within 3 d of injury. METHODS A multidisciplinary expert workgroup was established to define the most common concussion subtypes and their associated conditions and select clinical questions related to prevalence and recovery. A literature search was conducted from January 1, 1990 to November 1, 2017. Two experts abstracted study characteristics and results independently for each article selected for inclusion. A third expert adjudicated disagreements. Separate meta-analyses were conducted to do the following: 1) examine the prevalence of each subtype/associated condition in concussion patients using a proportion, 2) assess subtype/associated conditions in concussion compared to baseline/uninjured controls using a prevalence ratio, and 3) compare the differences in symptom scores between concussion subtypes and uninjured/baseline controls using a standardized mean difference (SMD). RESULTS The most prevalent concussion subtypes for pediatric and adult populations were headache/migraine (0.52; 95% CI = 0.37, 0.67) and cognitive (0.40; 95% CI = 0.25, 0.55), respectively. In pediatric patients, the prevalence of the vestibular subtype was also high (0.50; 95% CI = 0.40, 0.60). Adult patients were 4.4, 2.9, and 1.7 times more likely to demonstrate cognitive, vestibular, and anxiety/mood subtypes, respectively, as compared with their controls (P < .05). Children and adults with concussion showed significantly more cognitive symptoms than their respective controls (SMD = 0.66 and 0.24; P < .001). Furthermore, ocular-motor in adult patients (SMD = 0.72; P < .001) and vestibular symptoms in both pediatric and adult patients (SMD = 0.18 and 0.36; P < .05) were significantly worse in concussion patients than in controls. CONCLUSION Five concussion subtypes with varying prevalence within 3 d following injury are commonly seen clinically and identifiable upon systematic literature review. Sleep disturbance, a concussion-associated condition, is also common. There was insufficient information available for analysis of cervical strain. A comprehensive acute concussion assessment defines and characterizes the injury and, therefore, should incorporate evaluations of all 5 subtypes and associated conditions.
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Affiliation(s)
- Angela Lumba-Brown
- Department of Emergency Medicine, Brain Performance Center, Stanford University, Stanford, California
| | - Masaru Teramoto
- Division of Physical Medicine & Rehabilitation, University of Utah, Salt Lake City, Utah
| | - O Josh Bloom
- Carolina Sports Concussion Clinic, Cary, North Carolina
| | - David Brody
- Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - James Chesnutt
- Depts. of Family Medicine, Neurology, Orthopedics & Rehabilitation, Oregon Health & Science University, Portland, Oregon
| | - James R Clugston
- Departments of Community Health and Family Medicine and Neurology, University of Florida, Gainesville, Florida
| | - Michael Collins
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Gerard Gioia
- Division of Pediatric Neuropsychology, Safe Concussion Outcome Recovery & Education Program, Children's National Health System, Depts. of Pediatrics and Psychiatry & Behavioral Sciences, George Washington University School of Medicine, Rockville, Maryland
| | - Anthony Kontos
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Sports Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Avtar Lal
- Department of Neurosurgery, Concussion and Brain Performance Center, Stanford University, Stanford, California
| | - Allen Sills
- Department of Neurosurgery and Vanderbilt Sports Concussion Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jamshid Ghajar
- Department of Neurosurgery, Brain Performance Center, Stanford University, Stanford, California
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13
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Yousefzadeh-Chabok S, Kapourchali FR, Ramezani S. Determinants of long-term health-related quality of life in adult patients with mild traumatic brain injury. Eur J Trauma Emerg Surg 2019; 47:839-846. [DOI: 10.1007/s00068-019-01252-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 10/22/2019] [Indexed: 10/25/2022]
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14
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Shen IH, Lin YJ, Chen CL, Liao CC. Neural Correlates of Response Inhibition and Error Processing in Individuals with Mild Traumatic Brain Injury: An Event-Related Potential Study. J Neurotrauma 2019; 37:115-124. [PMID: 31317830 DOI: 10.1089/neu.2018.6122] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Individuals with a mild traumatic brain injury (mTBI) often have executive control deficits; however, the underlying neural mechanisms of such deficits are yet to be clarified. Inhibitory control and cognitive monitoring are two fundamental aspects of executive control processes. This study investigated the executive control of mTBI by using the Stop-signal task. Eighteen adults with mTBI and 18 age-, sex-, and education level-matched controls were recruited. Behavioral performance and event-related potential correlates of response inhibition and error processing were compared between groups. The mTBI group tended to have a lower probability of inhibition and a longer stop signal reaction time. N1 amplitude was greater on successful trials. Also on successful trials, N2 and P3 peaked earlier than on failed trials. The N2 amplitude of the mTBI group tended to be smaller than that of the controls. The control group had larger P3 amplitude on successful trials than on failed trials, whereas the mTBI group exhibited no P3 amplitudes difference between the two trial types. In addition, the mTBI group showed significantly longer error positivity latency than did the controls. These results suggest that inhibitory control and error processing were inefficient in the mTB group even more than three months after injury. Electrophysiological markers of cognitive dysfunction can be used as a sensitive tool for determining executive control after mTBI.
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Affiliation(s)
- I-Hsuan Shen
- Department of Occupational Therapy, Graduate Institute of Behavioral Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital Linkou branch, Taoyuan, Taiwan
| | - Ying-Ju Lin
- Department of Occupational Therapy, Graduate Institute of Behavioral Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Northern Service Center, Sunshine Social Welfare Foundation, Taipei, Taiwan
| | - Chia-Ling Chen
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital Linkou branch, Taoyuan, Taiwan.,Graduate Institute of Early Intervention, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Chih Liao
- Department of Neurosurgery, Division of Neurospine, Chang Gung Memorial Hospital Linkou branch, Taoyuan, Taiwan.,Department of Neurospinal Surgery, Mennonite Christian Hospital, Hualien, Taiwan
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15
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Polinder S, Cnossen MC, Real RGL, Covic A, Gorbunova A, Voormolen DC, Master CL, Haagsma JA, Diaz-Arrastia R, von Steinbuechel N. A Multidimensional Approach to Post-concussion Symptoms in Mild Traumatic Brain Injury. Front Neurol 2018; 9:1113. [PMID: 30619066 PMCID: PMC6306025 DOI: 10.3389/fneur.2018.01113] [Citation(s) in RCA: 209] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 12/05/2018] [Indexed: 12/14/2022] Open
Abstract
Mild traumatic brain injury (mTBI) presents a substantial burden to patients, families, and health care systems. Whereas, recovery can be expected in the majority of patients, a subset continues to report persisting somatic, cognitive, emotional, and/or behavioral problems, generally referred to as post-concussion syndrome (PCS). However, this term has been the subject of debate since the mechanisms underlying post-concussion symptoms and the role of pre- and post-injury-related factors are still poorly understood. We review current evidence and controversies concerning the use of the terms post-concussion symptoms vs. syndrome, its diagnosis, etiology, prevalence, assessment, and treatment in both adults and children. Prevalence rates of post-concussion symptoms vary between 11 and 82%, depending on diagnostic criteria, population and timing of assessment. Post-concussion symptoms are dependent on complex interactions between somatic, psychological, and social factors. Progress in understanding has been hampered by inconsistent classification and variable assessment procedures. There are substantial limitations in research to date, resulting in gaps in our understanding, leading to uncertainty regarding epidemiology, etiology, prognosis, and treatment. Future directions including the identification of potential mechanisms, new imaging techniques, comprehensive, multidisciplinary assessment and treatment options are discussed. Treatment of post-concussion symptoms is highly variable, and primarily directed at symptom relief, rather than at modifying the underlying pathology. Longitudinal studies applying standardized assessment strategies, diagnoses, and evidence-based interventions are required in adult and pediatric mTBI populations to optimize recovery and reduce the substantial socio-economic burden of post-concussion symptoms.
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Affiliation(s)
- Suzanne Polinder
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Maryse C Cnossen
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Ruben G L Real
- Institute of Medical Psychology and Medical Sociology, Georg-August-University, Göttingen, Germany
| | - Amra Covic
- Institute of Medical Psychology and Medical Sociology, Georg-August-University, Göttingen, Germany
| | - Anastasia Gorbunova
- Institute of Medical Psychology and Medical Sociology, Georg-August-University, Göttingen, Germany
| | - Daphne C Voormolen
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Christina L Master
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Juanita A Haagsma
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,Department of Emergency Medicine, Erasmus Medical Center Rotterdam, Rotterdam, Netherlands
| | - Ramon Diaz-Arrastia
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Nicole von Steinbuechel
- Institute of Medical Psychology and Medical Sociology, Georg-August-University, Göttingen, Germany
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16
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Abstract
PURPOSE OF REVIEW Headache is a frequent and debilitating symptom after mild traumatic brain injury, yet little is known about its pathophysiology and most effective treatments. The goal of this review is to summarize findings from imaging studies used during the clinical evaluation and research investigation of post-traumatic headache (PTH). RECENT FINDINGS There are no published recommendations or guidelines for when to acquire imaging studies of the head or neck in patients with PTH. Clinical acumen is required to determine if imaging is needed to assess for a secondary cause of headache which may have been precipitated or unmasked by the trauma. Several guidelines for when to image the patient with mild traumatic brain injury (mTBI) in the emergency setting consider headache among the deciding factors. In the research arena, imaging techniques including proton spectroscopy magnetic resonance imaging, diffusion tensor imaging, magnetic resonance morphometry, and functional neck x-rays have been employed with the goal of identifying diagnostic and prognostic factors for PTH and to help understand its underlying pathophysiologic mechanisms. Results indicate that changes in regional cortical thickness and damage to specific white matter tracts warrant further research. Future research should interrogate whether these imaging findings contribute to the classification and prognosis of PTH. Current research provides evidence that imaging findings associated with PTH may be distinct from those attributable to mTBI. A variety of imaging techniques have potential to further our understanding of the pathophysiologic processes underlying PTH as well as to provide diagnostic and prognostic indicators. However, considerable work must be undertaken for this to be realized.
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Affiliation(s)
- Jill C Rau
- Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA
| | - Gina M Dumkrieger
- Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA
| | - Catherine D Chong
- Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA
| | - Todd J Schwedt
- Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA.
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17
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Cnossen MC, van der Naalt J, Spikman JM, Nieboer D, Yue JK, Winkler EA, Manley GT, von Steinbuechel N, Polinder S, Steyerberg EW, Lingsma HF. Prediction of Persistent Post-Concussion Symptoms after Mild Traumatic Brain Injury. J Neurotrauma 2018; 35:2691-2698. [PMID: 29690799 DOI: 10.1089/neu.2017.5486] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Persistent post-concussion symptoms (PPCS) occur frequently after mild traumatic brain injury (mTBI). The identification of patients at risk for poor outcome remains challenging because valid prediction models are missing. The objectives of the current study were to assess the quality and clinical value of prediction models for PPCS and to develop a new model based on the synthesis of existing models and addition of complaints at the emergency department (ED). Patients with mTBI (Glasgow Coma Scale score 13-15) were recruited prospectively from three Dutch level I trauma centers between 2013 and 2015 in the UPFRONT study. PPCS were assessed using the Head Injury Severity Checklist at six months post-injury. Two prediction models (Stulemeijer 2008; Cnossen 2017) were examined for calibration and discrimination. The final model comprised variables of existing models with the addition of headache, nausea/vomiting, and neck pain at ED, using logistic regression and bootstrap validation. Overall, 591 patients (mean age 51years, 41% female) were included; PPCS developed in 241 (41%). Existing models performed poorly at external validation (area under the curve [AUC]: 0.57-0.64). The newly developed model included female sex (odds ratio [OR] 1.48, 95% confidence interval [CI] [1.01-2.18]), neck pain (OR 2.58, [1.39-4.78]), two-week post-concussion symptoms (OR 4.89, [3.19-7.49]) and two-week post-traumatic stress (OR 2.98, [1.88-4.73]) as significant predictors. Discrimination of this model was adequate (AUC after bootstrap validation: 0.75). Existing prediction models for PPCS perform poorly. A new model performs reasonably with predictive factors already discernible at ED warranting further external validation. Prediction research in mTBI should be improved by standardizing definitions and data collection and by using sound methodology.
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Affiliation(s)
- Maryse C Cnossen
- 1 Center for Medical Decision Making , Department of Public Health, Erasmus MC, Rotterdam, the Netherlands
| | - Joukje van der Naalt
- 2 Department of Neurology, University Medical Center Groningen , the Netherlands
| | - Joke M Spikman
- 2 Department of Neurology, University Medical Center Groningen , the Netherlands .,3 Department of Clinical and Developmental Neuropsychology, University of Groningen, University Medical Center Groningen , the Netherlands
| | - Daan Nieboer
- 1 Center for Medical Decision Making , Department of Public Health, Erasmus MC, Rotterdam, the Netherlands
| | - John K Yue
- 4 Department of Neurological Surgery, University of California , San Francisco, San Francisco, California.,5 Brain and Spinal Injury Center , San Francisco General Hospital, San Francisco, California
| | - Ethan A Winkler
- 4 Department of Neurological Surgery, University of California , San Francisco, San Francisco, California.,5 Brain and Spinal Injury Center , San Francisco General Hospital, San Francisco, California
| | - Geoffrey T Manley
- 4 Department of Neurological Surgery, University of California , San Francisco, San Francisco, California
| | - Nicole von Steinbuechel
- 6 Institute of Medical Psychology and Medical Sociology, Georg-August-University , Göttingen, Germany
| | - Suzanne Polinder
- 1 Center for Medical Decision Making , Department of Public Health, Erasmus MC, Rotterdam, the Netherlands
| | - Ewout W Steyerberg
- 1 Center for Medical Decision Making , Department of Public Health, Erasmus MC, Rotterdam, the Netherlands .,7 Department of Medical Statistics and Bioinformatics, Leiden University Medical Center , Leiden, the Netherlands
| | - Hester F Lingsma
- 1 Center for Medical Decision Making , Department of Public Health, Erasmus MC, Rotterdam, the Netherlands
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18
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Wijenberg MLM, Stapert SZ, Verbunt JA, Ponsford JL, Van Heugten CM. Does the fear avoidance model explain persistent symptoms after traumatic brain injury? Brain Inj 2017; 31:1597-1604. [DOI: 10.1080/02699052.2017.1366551] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Melloney L. M. Wijenberg
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands
- Limburg Brain Injury Centre, Limburg, The Netherlands
| | - Sven Z. Stapert
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands
- Department of Medical Psychology, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - Jeanine A. Verbunt
- Adelante, Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands
| | - Jennie L. Ponsford
- Department of Rehabilitation Medicine, Research School CAPHRI, Maastricht University, Maastricht, The Netherlands
- Monash-Epworth Rehabilitation Research Centre, Epworth Hospital, Richmond, Victoria, Australia
| | - Caroline M. Van Heugten
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands
- Limburg Brain Injury Centre, Limburg, The Netherlands
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
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19
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Lee JY, Yoon YH, Lewis RJ, Tolles J. Frequency of Post-Concussion Syndrome in Korean Patients with Minor Head Injury. JOURNAL OF TRAUMA AND INJURY 2017. [DOI: 10.20408/jti.2017.30.2.41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Ji Young Lee
- Department of Emergency Medicine, Korea University, Guro Hospital, Seoul, Korea
| | - Young Hoon Yoon
- Department of Emergency Medicine, Korea University, Guro Hospital, Seoul, Korea
| | - Roger J. Lewis
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
- Los Angeles Biomedical Research Institute, Torrance, California
- David Geffen School of Medicine, University of California, Los Angeles
| | - Juliana Tolles
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
- Los Angeles Biomedical Research Institute, Torrance, California
- David Geffen School of Medicine, University of California, Los Angeles
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20
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Yang CC, Chiu HC, Xiao SH, Tsai YH, Lee YC, Ku YT, Lin RS, Lin WC, Huang SJ. Iatrogenic Effect? Cautions when Utilizing an Early Health Education for Post-concussion Symptoms. Arch Clin Neuropsychol 2017; 33:131-142. [DOI: 10.1093/arclin/acx060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 06/09/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Chi-Cheng Yang
- Department of Psychology, National Chengchi University, Taipei, Taiwan
| | - Hsiao-Chun Chiu
- Pediatric Psychiatry, Chang-Gung Memorial Hospital, Taoyuan, Taiwan
| | - Sheng-Huang Xiao
- Department of Psychology, National Chengchi University, Taipei, Taiwan
- Taipei City Hospital Ren-Ai Branch, Taipei, Taiwan
| | - Yi-Hsin Tsai
- Department of Neurosurgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Yi-Chien Lee
- Department of Psychology, National Chengchi University, Taipei, Taiwan
| | - Yi-Ting Ku
- Department of Psychology, National Chengchi University, Taipei, Taiwan
| | - Rong-Syuan Lin
- Division of Clinical Psychology, Master of Behavioral Science, Department of Occupational Therapy, College of Medicine, Chang-Gung University, Taoyuan, Taiwan
| | - Wei-Chi Lin
- Division of Clinical Psychology, Master of Behavioral Science, Department of Occupational Therapy, College of Medicine, Chang-Gung University, Taoyuan, Taiwan
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Hellstrøm T, Kaufmann T, Andelic N, Soberg HL, Sigurdardottir S, Helseth E, Andreassen OA, Westlye LT. Predicting Outcome 12 Months after Mild Traumatic Brain Injury in Patients Admitted to a Neurosurgery Service. Front Neurol 2017; 8:125. [PMID: 28443058 PMCID: PMC5385465 DOI: 10.3389/fneur.2017.00125] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 03/16/2017] [Indexed: 01/16/2023] Open
Abstract
Objective Accurate outcome prediction models for patients with mild traumatic brain injury (MTBI) are key for prognostic assessment and clinical decision-making. Using multivariate machine learning, we tested the unique and added predictive value of (1) magnetic resonance imaging (MRI)-based brain morphometric and volumetric characterization at 4-week postinjury and (2) demographic, preinjury, injury-related, and postinjury variables on 12-month outcomes, including global functioning level, postconcussion symptoms, and mental health in patients with MTBI. Methods A prospective, cohort study of patients (n = 147) aged 16–65 years with a 12-month follow-up. T1-weighted 3 T MRI data were processed in FreeSurfer, yielding accurate cortical reconstructions for surface-based analyses of cortical thickness, area, and volume, and brain segmentation for subcortical and global brain volumes. The 12-month outcome was defined as a composite score using a principal component analysis including the Glasgow Outcome Scale Extended, Rivermead Postconcussion Questionnaire, and Patient Health Questionnaire-9. Using leave-one-out cross-validation and permutation testing, we tested and compared three prediction models: (1) MRI model, (2) clinical model, and (3) MRI and clinical combined. Results We found a strong correlation between observed and predicted outcomes for the clinical model (r = 0.55, p < 0.001). The MRI model performed at the chance level (r = 0.03, p = 0.80) and the combined model (r = 0.45, p < 0.002) were slightly weaker than the clinical model. Univariate correlation analyses revealed the strongest association with outcome for postinjury factors of posttraumatic stress (Posttraumatic Symptom Scale-10, r = 0.61), psychological distress (Hospital Anxiety and Depression Scale, r = 0.52), and widespread pain (r = 0.43) assessed at 8 weeks. Conclusion We found no added predictive value of MRI-based measures of brain cortical morphometry and subcortical volumes over and above demographic and clinical features.
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Affiliation(s)
- Torgeir Hellstrøm
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Tobias Kaufmann
- KG Jebsen Centre for Psychosis Research/Norwegian Centre for Mental Disorder Research (NORMENT), Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - Nada Andelic
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway.,Institute of Health and Society, CHARM Research Centre for Habilitation and Rehabilitation Models & Services, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Helene L Soberg
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | | | - Eirik Helseth
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Ole A Andreassen
- KG Jebsen Centre for Psychosis Research/Norwegian Centre for Mental Disorder Research (NORMENT), Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - Lars T Westlye
- KG Jebsen Centre for Psychosis Research/Norwegian Centre for Mental Disorder Research (NORMENT), Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway.,Department of Psychology, University of Oslo, Oslo, Norway
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Bloom BM, Kinsella K, Pott J, Patel HC, Harris T, Lecky F, Pearse R. Short-term neurocognitive and symptomatic outcomes following mild traumatic brain injury: A prospective multi-centre observational cohort study. Brain Inj 2017; 31:304-311. [PMID: 28156140 DOI: 10.1080/02699052.2016.1256501] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To determine the short-term cognitive and symptomatic outcome following mild traumatic brain injury. METHODS Setting: Emergency Departments of two UK tertiary referral hospitals. PARTICIPANTS Adult patients presenting to the Emergency Departments of the Royal London Hospital and Salford Royal Hospital with suspected traumatic brain injury within 24 hours and Glasgow Coma Score > 8. A non-TBI comparison group included adult patients with no head or neck injury. DESIGN Prospective multi-centre cohort study. MAIN MEASURES The Standardized Assessment of Concussion (SAC), the Concussion Symptom Inventory (CSI) and total number of symptoms, measured at baseline and 72 hours. RESULTS This study enrolled 189 patients with and 51 patients without TBI. Patients with TBI had marked cognitive impairment which persisted at 72 hours (SAC score at baseline = 25 [23-27] vs 72 hours = 25 [22-27]; p = 0.1). Patients with TBI had persistent high symptom severity, although this had decreased at 72 hours (CSI score at baseline = 9 [4-22] vs 72 hours = 5 [1-19], p = 0.002). A similar pattern was observed with the total number of symptoms (baseline = 4 [2-8] vs 72 hours = 0 [0-4]; p < 0.001). Patients with TBI had worse neurocognitive function, higher overall symptom severity and higher total number of symptoms compared with patients without TBI. Patients without TBI' neurocognitive function and symptom severity remained constant, but the number of symptoms reduced between baseline and 72 hours. CONCLUSION There is a cognitive deficit and symptom burden in patients with mild TBI presenting to the Emergency Department which persists at 72 hours.
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Affiliation(s)
- Benjamin M Bloom
- a William Harvey Institute , Queen Mary University of London , London , UK.,b Department of Emergency Medicine , Royal London Hospital , London , UK
| | - Kathryn Kinsella
- c Department of Emergency Medicine, Salford Healthcare Directorate , Salford Royal Foundation Trust , Salford , UK
| | - Jason Pott
- b Department of Emergency Medicine , Royal London Hospital , London , UK
| | - Hiren C Patel
- d Department of Neurosurgery , Salford Royal NHS Foundation Trust , Salford , UK
| | - Tim Harris
- a William Harvey Institute , Queen Mary University of London , London , UK.,b Department of Emergency Medicine , Royal London Hospital , London , UK
| | - Fiona Lecky
- c Department of Emergency Medicine, Salford Healthcare Directorate , Salford Royal Foundation Trust , Salford , UK.,e School of Health and Related Research , University of Sheffield , Sheffield , UK.,f Trauma Audit and Research Network, Institute of Population Health , University of Manchester , Manchester , UK
| | - Rupert Pearse
- a William Harvey Institute , Queen Mary University of London , London , UK
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23
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Varner CE, McLeod S, Nahiddi N, Lougheed RE, Dear TE, Borgundvaag B. Cognitive Rest and Graduated Return to Usual Activities Versus Usual Care for Mild Traumatic Brain Injury: A Randomized Controlled Trial of Emergency Department Discharge Instructions. Acad Emerg Med 2017; 24:75-82. [PMID: 27792852 DOI: 10.1111/acem.13073] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 08/18/2016] [Accepted: 08/23/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVES It is estimated that 15%-25% of patients with a mild traumatic brain injury (MTBI) diagnosed in the emergency department (ED) will develop postconcussive syndrome. The objective of this study was to determine if patients randomized to graduated return to usual activity discharge instructions had a decrease in their Post-Concussion Symptom Score (PCSS) 2 weeks after MTBI compared to patients who received usual care MTBI discharge instructions. METHODS This was a pragmatic, randomized trial of adult (18-64 years) patients of an academic ED (annual census 60,000) diagnosed with MTBI occurring within 24 hours of ED visit. The intervention group received cognitive rest and graduated return to usual activity discharge instructions, and the control group received usual care discharge instructions that did not instruct cognitive rest or graduated return. Patients were contacted by text message or phone 2 and 4 weeks post-ED discharge and asked to complete the PCSS, a validated, 22-item questionnaire, to determine if there was a change in their symptoms. Secondary outcomes included change in PCSS at 4 weeks, number follow-up physician visits, and time off work/school. RESULTS A total of 118 patients were enrolled in the study (58 in the control group and 60 in the intervention). The mean (±SD) age was 35.2 (±13.7) years and 43 (36.4%) were male. There was no difference with respect to change in PCSS at 2 weeks (10.5 vs. 12.8; ∆2.3, 95% confidence interval [CI] = 7.0 to 11.7) and 4 weeks post-ED discharge (21.1 vs 18.3; ∆2.8, 95% CI = 6.9 to 12.7) for the intervention and control groups, respectively. The number of follow-up physician visits and time off work/school were similar when the groups were compared. Thirty-eight (42.2%) and 23 (30.3%) of patients in this cohort had ongoing MTBI symptoms (PCSS > 20) at 2 and 4 weeks, respectively. CONCLUSIONS Results from this study suggest graduated return to usual activity discharge instructions do not impact rate of resolution of MTBI symptoms 2 weeks after ED discharge. Given that patients continue to experience symptoms 2 and 4 weeks after MTBI, more investigation is needed to determine how best to counsel and treat patients with postconcussive symptoms.
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Affiliation(s)
- Catherine E. Varner
- Department of Family and Community Medicine University of Toronto Toronto Ontario
- Department of Emergency Medicine Mount Sinai Hospital Toronto Ontario Canada
- Schwartz/Reisman Emergency Medicine Institute Mount Sinai Hospital Toronto Ontario Canada
| | - Shelley McLeod
- Department of Family and Community Medicine University of Toronto Toronto Ontario
- Department of Emergency Medicine Mount Sinai Hospital Toronto Ontario Canada
- Schwartz/Reisman Emergency Medicine Institute Mount Sinai Hospital Toronto Ontario Canada
| | - Negine Nahiddi
- Department of Family and Community Medicine University of Toronto Toronto Ontario
| | - Rosamond E. Lougheed
- Department of Family and Community Medicine University of Toronto Toronto Ontario
| | - Taylor E. Dear
- Schwartz/Reisman Emergency Medicine Institute Mount Sinai Hospital Toronto Ontario Canada
| | - Bjug Borgundvaag
- Department of Family and Community Medicine University of Toronto Toronto Ontario
- Department of Emergency Medicine Mount Sinai Hospital Toronto Ontario Canada
- Schwartz/Reisman Emergency Medicine Institute Mount Sinai Hospital Toronto Ontario Canada
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Reddy RP, Rajeswaran J, Devi BI, Kandavel T. Cascade of Traumatic Brain Injury: A Correlational Study of Cognition, Postconcussion Symptoms, and Quality of Life. Indian J Psychol Med 2017; 39:32-39. [PMID: 28250556 PMCID: PMC5329988 DOI: 10.4103/0253-7176.198940] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Traumatic brain injury (TBI) constitutes a significant burden on health care resources in India. TBI is a dynamic process which involves damage to the brain thus leading to behavior cognitive and emotional consequences. AIM To study the cognitive profile, post-concussion symptoms (PCS), quality of life (QOL), and their correlation. METHODS A total of 60 patients with TBI were recruited and assessed for neuropsychological profile, PCS, and QOL, the correlation among the variables were analyzed. RESULTS The results suggest that TBI has series of consequences which is interrelated, and the study has implications for rehabilitation of TBI. CONCLUSION The study highlights the deficits of cognition, and its correlation with PCS and QOL, emphasizing integrated rehabilitation approach for patients with TBI.
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Affiliation(s)
- Rajakumari Pampa Reddy
- Department of Clinical Psychology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Jamuna Rajeswaran
- Department of Clinical Psychology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - B Indira Devi
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Thennarasu Kandavel
- Department of Biostatistics, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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25
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Lin LF, Liou TH, Hu CJ, Ma HP, Ou JC, Chiang YH, Chiu WT, Tsai SH, Chu WC. Balance function and sensory integration after mild traumatic brain injury. Brain Inj 2016; 29:41-6. [PMID: 25265292 DOI: 10.3109/02699052.2014.955881] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE This study examined the disparities in balance functions and sensory integration in patients with mild traumatic brain injuries (mTBIs) and healthy controls. PARTICIPANTS One hundred and seven patients with mTBI and 107 age- and sex-matched controls were recruaited for this study. PRIMARY MEASURES Symptoms of dizziness, balance functions and the ability to perform daily activities were assessed using the dizziness handicap inventory (DHI). This study also performed the postural-stability test and a modified clinical test of sensory integration by using the Biodex Stability System (BBS). RESULTS DHI scores (functional, emotional, physical and total self-reported scores) were substantially increased in patients following an mTBI compared with the scores of the controls (p < 0.000). The postural-stability test indices (anterior-posterior) (p = 0.045) and the sensory-integration test index (eyes-open-firm-surface index) (p = 0.006) were substantially lower in patients with mTBI than in the controls. However, indices of two other postural-stability test indices (overall and medial-lateral) and three other sensory-integration tests indices (eyes-closed-firm-surface, eyes-open-foam-surface and eyes-closed-foam-surface) measured for the mTBI group did not differ from those of the control group. CONCLUSION Activities of daily living, balance in postural stability and sensory integration were strongly impaired in patients with mTBI.
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Affiliation(s)
- Li-Fong Lin
- a Graduate Institute of Biomedical Engineering, National Yang-Ming University , Taiwan ROC
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26
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Cognition in the Emergency Department as a Predictor of Recovery after Pediatric Mild Traumatic Brain Injury. J Int Neuropsychol Soc 2016; 22:379-87. [PMID: 26786357 DOI: 10.1017/s1355617715001368] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Cognitive abilities can be acutely disrupted in children and adolescents who sustain a mild traumatic brain injury (mTBI), with the potential that these disruptions may be predictive of recovery. The objective of this study was to determine if cognitive abilities in the emergency department (ED) can differentiate and predict poor symptom recovery following a pediatric mTBI. Participants included 77 male and female youth with a mTBI (mean age=13.6; SD=2.6). All participants completed computerized cognitive testing (four subtests from the CNS Vital Signs) when they presented to the ED. Symptom measurement occurred in the ED (for pre-injury), at 7-10 days, 1 month, 2 months, and 3 months post-mTBI using the post-concussion symptom inventory (PCSI). Recovery was determined using reliable change scores for symptom ratings from 28 orthopedic injury controls (mean age=13.9 years; SD=2.1). Significantly worse Reaction Time scores (i.e., rapid information processing) in the ED were found in those who remained symptomatic at 1 month. Performances on the Reaction Time and Cognitive Flexibility domain scores were predictive of symptom outcome at 1 month for youth (above and beyond sex and baseline symptom burden). Youth with low scores on Reaction Time and/or Cognitive Flexibility were nearly 15 times (95% CI=1.8-323.5) more likely to remain symptomatic at 1 month post-mTBI. No significant group differences were found at 7-10 days, 2 months, or 3 months post-injury. Rapid computerized cognitive testing in the ED following a mTBI may help clinicians predict which youth may or may not remain symptomatic at follow-up.
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Individuals With Traumatic Brain Injury and Their Significant Others' Perceptions of Information Given About the Nature and Possible Consequences of Brain Injury. Prof Case Manag 2016; 21:22-33; quiz E3-4. [DOI: 10.1097/ncm.0000000000000121] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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28
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Oldenburg C, Lundin A, Edman G, Nygren-de Boussard C, Bartfai A. Cognitive reserve and persistent post-concussion symptoms—A prospective mild traumatic brain injury (mTBI) cohort study. Brain Inj 2015; 30:146-55. [DOI: 10.3109/02699052.2015.1089598] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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29
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Fischer TD, Red SD, Chuang AZ, Jones EB, McCarthy JJ, Patel SS, Sereno AB. Detection of Subtle Cognitive Changes after mTBI Using a Novel Tablet-Based Task. J Neurotrauma 2015; 33:1237-46. [PMID: 26398492 DOI: 10.1089/neu.2015.3990] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This study examined the potential for novel tablet-based tasks, modeled after eye tracking techniques, to detect subtle sensorimotor and cognitive deficits after mild traumatic brain injury (mTBI). Specifically, we examined whether performance on these tablet-based tasks (Pro-point and Anti-point) was able to correctly categorize concussed versus non-concussed participants, compared with performance on other standardized tests for concussion. Patients admitted to the emergency department with mTBI were tested on the Pro-point and Anti-point tasks, a current standard cognitive screening test (i.e., the Standard Assessment of Concussion [SAC]), and another eye movement-based tablet test, the King-Devick(®) (KD). Within hours after injury, mTBI patients showed significant slowing in response times, compared with both orthopedic and age-matched control groups, in the Pro-point task, demonstrating deficits in sensorimotor function. Mild TBI patients also showed significant slowing, compared with both control groups, on the Anti-point task, even when controlling for sensorimotor slowing, indicating deficits in cognitive function. Performance on the SAC test revealed similar deficits of cognitive function in the mTBI group, compared with the age-matched control group; however, the KD test showed no evidence of cognitive slowing in mTBI patients, compared with either control group. Further, measuring the sensitivity and specificity of these tasks to accurately predict mTBI with receiver operating characteristic analysis indicated that the Anti-point and Pro-point tasks reached excellent levels of accuracy and fared better than current standardized tools for assessment of concussion. Our findings suggest that these rapid tablet-based tasks are able to reliably detect and measure functional impairment in cognitive and sensorimotor control within hours after mTBI. These tasks may provide a more sensitive diagnostic measure for functional deficits that could prove key to earlier detection of concussion, evaluation of interventions, or even prediction of persistent symptoms.
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Affiliation(s)
- Tara D Fischer
- 1 Department of Neurobiology and Anatomy, the University of Texas Health Science Center at Houston , Houston, Texas
| | - Stuart D Red
- 1 Department of Neurobiology and Anatomy, the University of Texas Health Science Center at Houston , Houston, Texas
| | - Alice Z Chuang
- 2 Department of Ophthalmology and Visual Science, the University of Texas Health Science Center at Houston , Houston, Texas
| | - Elizabeth B Jones
- 3 Department of Emergency Medicine, the University of Texas Health Science Center at Houston , Houston, Texas
| | - James J McCarthy
- 3 Department of Emergency Medicine, the University of Texas Health Science Center at Houston , Houston, Texas
| | - Saumil S Patel
- 4 Department of Neuroscience, Baylor College of Medicine , Houston, Texas
| | - Anne B Sereno
- 1 Department of Neurobiology and Anatomy, the University of Texas Health Science Center at Houston , Houston, Texas
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Piponnier JC, Forget R, Gagnon I, McKerral M, Giguère JF, Faubert J. First- and Second-Order Stimuli Reaction Time Measures Are Highly Sensitive to Mild Traumatic Brain Injuries. J Neurotrauma 2015; 33:242-53. [PMID: 25950948 DOI: 10.1089/neu.2014.3832] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Mild traumatic brain injury (mTBI) has subtle effects on several brain functions that can be difficult to assess and follow up. We investigated the impact of mTBI on the perception of sine-wave gratings defined by first- and second-order characteristics. Fifteen adults diagnosed with mTBI were assessed at 15 days, 3 months, and 12 months postinjury. Fifteen matched controls followed the same testing schedule. Reaction times (RTs) for flicker detection and motion direction discrimination were measured. Stimulus contrast of first- and second-order patterns was equated to control for visibility, and correct-response RT means, standard deviations (SDs), medians, and interquartile ranges (IQRs) were calculated. The level of symptoms was also evaluated to compare it to RT data. In general in mTBI, RTs were longer, and SDs as well as IQRs larger, than those of controls. In addition, mTBI participants' RTs to first-order stimuli were shorter than those to second-order stimuli, and SDs as well as IQRs larger for first- than for second-order stimuli in the motion condition. All these observations were made over the three sessions. The level of symptoms observed in mTBI was higher than that of control participants, and this difference did also persist up to 1 year after the brain injury, despite an improvement. The combination of RT measures with particular stimulus properties is a highly sensitive method for measuring mTBI-induced visuomotor anomalies and provides a fine probe of the underlying mechanisms when the brain is exposed to mild trauma.
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Affiliation(s)
- Jean-Claude Piponnier
- 1 Visual Psychophysics and Perception Laboratory, École d'Optométrie, Université de Montréal , Montréal, QC, Canada
| | - Robert Forget
- 2 École de réadaptation, Université de Montréal , and Centre de recherche interdisciplinaire en réadaptation du Montréal métropolitain, Montréal, QC, Canada
| | - Isabelle Gagnon
- 3 Montreal Children's Hospital, McGill University Health Center, and School of Physical and Occupational Therapy, McGill University , Montreal, Montréal, QC, Canada
| | - Michelle McKerral
- 4 Centre de recherche interdisciplinaire en réadaptation-Centre de réadaptation Lucie-Bruneau, and Département de psychologie, Université de Montréal , Montréal, QC, Canada
| | - Jean-François Giguère
- 5 Department of Surgery, Sacré-Coeur Hospital affiliated with Université de Montréal , Montréal, QC, Canada
| | - Jocelyn Faubert
- 1 Visual Psychophysics and Perception Laboratory, École d'Optométrie, Université de Montréal , Montréal, QC, Canada
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Norris JN, Smith S, Harris E, Labrie DW, Ahlers ST. Characterization of acute stress reaction following an IED blast-related mild traumatic brain injury. Brain Inj 2015; 29:898-904. [PMID: 25955118 DOI: 10.3109/02699052.2015.1022879] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PRIMARY OBJECTIVE To characterize an acute stress reaction (ASR) following an improvised explosive device (IED) blast-related mild traumatic brain injury (mTBI). RESEARCH DESIGN Participants were male, US military personnel treated in Afghanistan within 4 days following an IED-related mTBI event (n = 239). METHODS AND PROCEDURES Demographics, diagnosis of ASR, injury history and self-reported mTBIs, blast exposures and psychological health histories were recorded. MAIN OUTCOMES AND RESULTS In total, 12.5% of patients met ASR criteria. Patients with ASR were significantly younger and junior in rank (p < 0.05). Patients with ASR were more likely to experience the IED-blast while dismounted, report a loss of consciousness (LOC) and higher pain levels (p < 0.05). Adjusting for age and rank, multivariate logistic regression showed an association between mTBI history and ASR (AOR = 1.405; 95% CI = 1.105-1.786, p < 0.01). Adjusting for mechanism of injury (dismounted vs. mounted), LOC and pain, multivariate logistic regression showed an association between mTBI history and ASR (AOR = 1.453; 95% CI = 1.132-1.864, p < 0.01). Prior blast exposure and past psychological health issues were not associated with ASR. CONCLUSIONS A history of multiple mTBIs is associated with increased risk of ASR. Future research is warranted.
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Affiliation(s)
- Jacob N Norris
- Neurotrauma Department, Naval Medical Research Center , Silver Spring, MD , USA
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Silverberg ND, Gardner AJ, Brubacher JR, Panenka WJ, Li JJ, Iverson GL. Systematic Review of Multivariable Prognostic Models for Mild Traumatic Brain Injury. J Neurotrauma 2015; 32:517-26. [DOI: 10.1089/neu.2014.3600] [Citation(s) in RCA: 198] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Noah D. Silverberg
- University of British Columbia and GF Strong Rehab Centre, Vancouver, British Columbia, Canada
| | - Andrew J. Gardner
- Centre for Translational Neuroscience and Mental Health, School of Medicine and Public Health, University of Newcastle, Waratah, New South Wales, Australia
| | - Jeffrey R. Brubacher
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - William J. Panenka
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jun Jian Li
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Grant L. Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School; Spaulding Rehabilitation Hospital; Massachusetts General Hospital Sport Concussion Clinic; and Red Sox Foundation and Massachusetts General Hospital Home Base Program, Charlestown, Massachusetts
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33
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Faux SG, Kohler F, Mozer R, Klein LA, Courtenay S, D’Amours SK, Chapman J, Estell J. The ROARI project – Road Accident Acute Rehabilitation Initiative: a randomised clinical trial of two targeted early interventions for road-related trauma. Clin Rehabil 2014; 29:639-52. [DOI: 10.1177/0269215514552083] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 08/27/2014] [Indexed: 01/30/2023]
Abstract
Objectives: To determine the effectiveness of an Early Rehabilitation Intervention (ERI ) versus a Brief Education Intervention (BEI) following road trauma. Primary objective: return to work or usual activities at 12 weeks (for minor/moderate injury) and 24 weeks for major injury. Secondary objectives: Reduction in pain, anxiety, depression, disability and incidence of Post Traumatic Stress Disorder and improved quality of life. Design: A multi-site single-blinded stratified randomized clinical trial (RCT). Methods: 184 patients (92 in each arm) were recruited over 18 months and followed for 12 weeks (minor/moderate injury) and 24 weeks (major injury). Screening questionnaires at 2-4 weeks and follow-up interviews by phone for all outcome measures were undertaken. For those in the ERI group with a positive screen for high risk of persistent symptoms, an early assessment and intervention by a Rehabilitation Physician was offered. Those in the BEI group were sent written information and advised to see their GP. Results: 89.4% of injuries were mild in this cohort. At 12 weeks 73.8% and 69.1% of patients in the ERI and the BEI groups respectively had returned to work or usual activities. There were no significant differences between the two intervention groups with respect to the primary or any secondary outcome measures. Conclusion: This is the first RCT of an ERI following road trauma in Australia. A targeted ERI is as effective as a BEI in assisting those with mild/moderate trauma to return to work or usual activities.
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Affiliation(s)
- SG Faux
- University of New South Wales, Australia
- St Vincent’s Hospital, Sydney, Australia
| | - F Kohler
- University of New South Wales, Australia
- Liverpool Hospital, Australia
| | - R Mozer
- St Vincent’s Hospital, Sydney, Australia
| | | | | | - SK D’Amours
- University of New South Wales, Australia
- Liverpool Hospital, Australia
| | - J Chapman
- Liverpool Hospital, Australia
- Westmead Hospital, Australia
| | - J Estell
- University of New South Wales, Australia
- St George Hospital, Australia
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Lange RT, Brickell TA, Kennedy JE, Bailie JM, Sills C, Asmussen S, Amador R, Dilay A, Ivins B, French LM. Factors influencing postconcussion and posttraumatic stress symptom reporting following military-related concurrent polytrauma and traumatic brain injury. Arch Clin Neuropsychol 2014; 29:329-47. [PMID: 24723461 DOI: 10.1093/arclin/acu013] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The purpose of this study was to identify factors that are predictive of, or associated with, high endorsement of postconcussion and posttraumatic stress symptoms following military-related traumatic brain injury (TBI). Participants were 1,600 U.S. service members (age: M = 27.1, SD = 7.1; 95.4% male) who had sustained a mild-to-moderate TBI and who had been evaluated by the Defense and Veterans Brain Injury Center at one of six military medical centers. Twenty-two factors were examined that included demographic, injury circumstances/severity, treatment/evaluation, and psychological/physical variables. Four factors were statistically and meaningfully associated with clinically elevated postconcussion symptoms: (i) low bodily injury severity, (ii) posttraumatic stress, (iii) depression, and (iv) military operation where wounded (p < .001, 43.2% variance). The combination of depression and posttraumatic stress symptoms accounted for the vast majority of unique variance (41.5%) and were strongly associated with, and predictive of, clinically elevated postconcussion symptoms [range: odds ratios (OR) = 4.24-7.75; relative risk (RR) = 2.28-2.51]. Five factors were statistically and meaningfully associated with clinically elevated posttraumatic stress symptoms: (i) low bodily injury severity, (ii) depression, (iii) a longer time from injury to evaluation, (iv) military operation where wounded, and (v) current auditory deficits (p < .001; 65.6% variance accounted for). Depression alone accounted for the vast majority of unique variance (60.0%) and was strongly associated with, and predictive of, clinically elevated posttraumatic stress symptoms (OR = 38.78; RR = 4.63). There was a very clear, strong, and clinically meaningful association between depression, posttraumatic stress, and postconcussion symptoms in this sample. Brain injury severity, however, was not associated with symptom reporting following TBI.
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Affiliation(s)
- Rael T Lange
- Defense and Veterans Brain Injury Center, Bethesda, MD, USA Walter Reed National Military Medical Center, Bethesda, MD, USA University of British Columbia, Vancouver, BC, Canada Center for Neuroscience and Regenerative Medicine, Bethesda, MD, USA
| | - Tracey A Brickell
- Defense and Veterans Brain Injury Center, Bethesda, MD, USA Walter Reed National Military Medical Center, Bethesda, MD, USA Uniformed Services University of the Health Sciences, Bethesda, MD, USA Center for Neuroscience and Regenerative Medicine, Bethesda, MD, USA
| | - Jan E Kennedy
- Defense and Veterans Brain Injury Center, Bethesda, MD, USA San Antonio Military Medical Center, Fort Sam Houston, TX, USA
| | - Jason M Bailie
- Defense and Veterans Brain Injury Center, Bethesda, MD, USA Naval Medical Center San Diego, San Diego, CA, USA
| | - Cheryl Sills
- Defense and Veterans Brain Injury Center, Bethesda, MD, USA San Antonio Military Medical Center, Fort Sam Houston, TX, USA
| | - Sarah Asmussen
- Defense and Veterans Brain Injury Center, Bethesda, MD, USA 33 Area Branch Clinic Camp Pendleton, Camp Pendleton, CA, USA
| | - Ricardo Amador
- Defense and Veterans Brain Injury Center, Bethesda, MD, USA San Antonio Military Medical Center, Fort Sam Houston, TX, USA
| | - Angelica Dilay
- Defense and Veterans Brain Injury Center, Bethesda, MD, USA Naval Medical Center San Diego, San Diego, CA, USA
| | - Brian Ivins
- Defense and Veterans Brain Injury Center, Bethesda, MD, USA
| | - Louis M French
- Defense and Veterans Brain Injury Center, Bethesda, MD, USA Walter Reed National Military Medical Center, Bethesda, MD, USA Uniformed Services University of the Health Sciences, Bethesda, MD, USA Center for Neuroscience and Regenerative Medicine, Bethesda, MD, USA
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Wojcik SM. Predicting mild traumatic brain injury patients at risk of persistent symptoms in the Emergency Department. Brain Inj 2014; 28:422-30. [PMID: 24564636 DOI: 10.3109/02699052.2014.884241] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To identify factors that can predict which emergency department (ED) patients with mTBI are likely to develop persistent post-concussion symptoms (PPCS). DESIGN A matched case-control study was conducted at a Level 1 trauma centre between June 2006 and July 2009. Patients diagnosed with mTBI in the ED and diagnosed at a concussion management programme with at least one PPCS (85 cases) were compared to patients diagnosed with mTBI in the ED (340 controls) to determine if factors assessed at the time of ED presentation could predict patients likely to develop persistent symptoms. RESULTS Multivariable hierarchical logistic regression with variables indicating increased risk for PPCS (prior mTBI, history of depression, history of anxiety, multiple injury, forgetfulness/poor memory, noise sensitivity, or light sensitivity) resulted in a final predictive model including prior mTBI, history of anxiety, forgetfulness/poor memory and light sensitivity. The final model had a specificity of 87.9% and a sensitivity of 69.9%. CONCLUSIONS A strong prediction model to identify those ED patients with mTBI at risk for PPCS was developed and could be easily implemented in the ED; therefore, helping to target those patients who would potentially benefit from close follow-up.
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Affiliation(s)
- Susan M Wojcik
- Department of Emergency Medicine, Upstate Medical University , Syracuse, NY , USA
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Reuben A, Sampson P, Harris AR, Williams H, Yates P. Postconcussion syndrome (PCS) in the emergency department: predicting and pre-empting persistent symptoms following a mild traumatic brain injury. Emerg Med J 2013; 31:72-7. [DOI: 10.1136/emermed-2012-201667] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Larrabee GJ, Binder LM, Rohling ML, Ploetz DM. Meta-analytic methods and the importance of non-TBI factors related to outcome in mild traumatic brain injury: response to Bigler et al. (2013). Clin Neuropsychol 2013; 27:215-37. [PMID: 23414416 DOI: 10.1080/13854046.2013.769634] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Bigler et al. (2013, The Clinical Neuropsychologist) contend that weak methodology and poor quality of the studies comprising our recent meta-analysis led us to miss detecting a subgroup of mild traumatic brain injury (mTBI) characterized by persisting symptomatic complaint and positive biomarkers for neurological damage. Our computation of non-significant Q, tau(2), and I(2) statistics contradicts the existence of a subgroup of mTBI with poor outcome, or variation in effect size as a function of quality of research design. Consistent with this conclusion, the largest single contributor to our meta-analysis, Dikmen, Machamer, Winn, and Temkin (1995, Neuropsychology, 9, 80) yielded an effect size, -0.02, that was smaller than our overall effect size of -0.07 despite using the most liberal definition of mTBI: loss of consciousness less than 1 hour, with no exclusion of subjects who had positive CT scans. The evidence is weak for biomarkers of mTBI, such as diffusion tensor imaging and for demonstrable neuropathology in uncomplicated mTBI. Postconcussive symptoms, and reduced neuropsychological test scores are not specific to mTBI but can result from pre-existing psychosocial and psychiatric problems, expectancy effects and diagnosis threat. Moreover, neuropsychological impairment is seen in a variety of primary psychiatric disorders, which themselves are predictive of persistent complaints following mTBI. We urge use of prospective studies with orthopedic trauma controls in future investigations of mTBI to control for these confounding factors.
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Lange RT, Brickell T, French LM, Ivins B, Bhagwat A, Pancholi S, Iverson GL. Risk Factors for Postconcussion Symptom Reporting after Traumatic Brain Injury in U.S. Military Service Members. J Neurotrauma 2013; 30:237-46. [DOI: 10.1089/neu.2012.2685] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Rael T. Lange
- Defense and Veterans Brain Injury Center, North Bethesda, Maryland
- Walter Reed National Military Medical Center, Bethesda, Maryland
- University of British Columbia, Vancouver, British Columbia, Canada
- Center for Neuroscience and Regenerative Medicine, Bethesda, Maryland
| | - Tracey Brickell
- Defense and Veterans Brain Injury Center, North Bethesda, Maryland
- Walter Reed National Military Medical Center, Bethesda, Maryland
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
- Center for Neuroscience and Regenerative Medicine, Bethesda, Maryland
| | - Louis M. French
- Defense and Veterans Brain Injury Center, North Bethesda, Maryland
- Walter Reed National Military Medical Center, Bethesda, Maryland
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
- Center for Neuroscience and Regenerative Medicine, Bethesda, Maryland
| | - Brian Ivins
- Defense and Veterans Brain Injury Center, North Bethesda, Maryland
| | - Aditya Bhagwat
- Defense and Veterans Brain Injury Center, North Bethesda, Maryland
- Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Sonal Pancholi
- Defense and Veterans Brain Injury Center, North Bethesda, Maryland
- Fort Belvoir Community Hospital, Fort Belvoir, Virginia
| | - Grant L. Iverson
- Defense and Veterans Brain Injury Center, North Bethesda, Maryland
- University of British Columbia, Vancouver, British Columbia, Canada
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Bigler ED, Farrer TJ, Pertab JL, James K, Petrie JA, Hedges DW. Reaffirmed Limitations of Meta-Analytic Methods in the Study of Mild Traumatic Brain Injury: A Response to Rohling et al. Clin Neuropsychol 2013; 27:176-214. [DOI: 10.1080/13854046.2012.693950] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Erin D. Bigler
- a Department of Psychology , Brigham Young University , Provo , UT , USA
- b Neuroscience Center, Brigham Young University , Provo , UT , USA
- c Department of Psychiatry , University of Utah , Salt Lake City , UT , USA
- d The Brain Institute of Utah, University of Utah , Salt Lake City , UT , USA
| | - Thomas J. Farrer
- a Department of Psychology , Brigham Young University , Provo , UT , USA
| | - Jon L. Pertab
- a Department of Psychology , Brigham Young University , Provo , UT , USA
- e Veterans Administration Hospital , Salt Lake City , UT , USA
| | - Kelly James
- a Department of Psychology , Brigham Young University , Provo , UT , USA
| | - Jo Ann Petrie
- a Department of Psychology , Brigham Young University , Provo , UT , USA
| | - Dawson W. Hedges
- a Department of Psychology , Brigham Young University , Provo , UT , USA
- b Neuroscience Center, Brigham Young University , Provo , UT , USA
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Preece MHW, Geffen GM, Horswill MS. Return-to-driving expectations following mild traumatic brain injury. Brain Inj 2012; 27:83-91. [DOI: 10.3109/02699052.2012.722260] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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The Association between Pain-Related Variables, Emotional Factors, and Attentional Functioning following Mild Traumatic Brain Injury. Rehabil Res Pract 2012; 2012:924692. [PMID: 22577557 PMCID: PMC3347753 DOI: 10.1155/2012/924692] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Accepted: 02/06/2012] [Indexed: 11/17/2022] Open
Abstract
This study examined how MTBI concomitants such as pain variables, depression, and anxiety were related to attentional functioning at different stages of recovery. Participants having sustained a MTBI who were in the earlier phase of recovery showed, compared to controls, slower reaction times and larger intra-individual variability on a Computerized Pictorial Stroop Task (CPST). They also reported more post-concussion symptoms, pain intensity and disability, whereas MTBI participants who were in the later phase of recovery presented a higher rate of post-concussive symptoms and somewhat higher pain intensity/disability. MTBI participants' scores on the cognitive items of the post-concussion symptoms scale were positively correlated with reaction times on the CPST, while pain intensity/disability levels were negatively correlated with standard attention measures. Results indicate that obtaining response times and intra-individual variability measures using tests such as the CPST represents an effective means for measuring recovery of attentional function, and that pain intensity/disability should be systematically assessed after a MTBI.
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Abstract
Sports-related concussions are complex injuries with biomechanical and biochemical etiology that present with central and autonomic nervous system dysfunction. Current methods for assessing concussions and basing return-to-play decisions rely on symptom resolution, rating scales, and neuropsychological testing, all of which are indirect measures of injury severity and detect functional capabilities but do not directly measure injury location or severity. In addition, these downstream measures are susceptible to false negatives because compensatory mechanism, such as unmasking and redundancies in brain circuitry can return functional capabilities before injury resolution. The multifactorial nature of concussion necessitates rapid, inexpensive, and easily applied multimodal analysis methods that can offer greater sensitivity and specificity. This article discusses how new approaches utilizing electrophysiology (e.g., QEEG, ERP, ECG, HRV), quantified balance measures, and biochemistry are necessary to advance the science of concussion assessment, treatment, recovery projections, and return-to-play decisions. These additional assessment tools offer a more direct window into the severity and location of the injury, real-time measures of brain function, and the ability to measure the multiple body systems negatively affected by concussion.
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The Value of Serum Biomarkers in Prediction Models of Outcome After Mild Traumatic Brain Injury. ACTA ACUST UNITED AC 2011; 71:S478-86. [PMID: 22072007 DOI: 10.1097/ta.0b013e318232fa70] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Grubenhoff JA, Kirkwood MW, Deakyne S, Wathen J. Detailed concussion symptom analysis in a paediatric ED population. Brain Inj 2011; 25:943-9. [PMID: 21749192 DOI: 10.3109/02699052.2011.597043] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PRIMARY OBJECTIVE To examine the frequency of acute mild traumatic brain injury (mTBI) symptoms in children using a concussion symptom inventory and to identify which symptoms are most useful in identifying mTBI. It was hypothesized that symptoms associated with mTBI are more common in children with head injury than orthopaedic injury and certain symptoms are more useful than others in identifying mTBI. RESEARCH DESIGN Prospective case-control study conducted in a paediatric trauma centre emergency department. METHODS AND PROCEDURES Children of 6-18 years old with head injury or a minor extremity injury were enrolled. Symptoms were assessed using a graded symptom checklist. Symptom frequency was compared using a chi-square test. The association between individual symptoms with AMS was evaluated with logistic regression analysis. MAIN OUTCOMES AND RESULTS Children with head injury displayed more frequent symptoms than controls. Head-injured cases with altered mental status (AMS) demonstrated the most frequent and severe symptoms (median symptom scores: control = 1, cases without AMS = 5, cases with AMS = 10; p < 0.001). Headache, nausea, dizziness, blurred/double vision and not feeling 'sharp' were associated with AMS. CONCLUSIONS Symptoms associated with mTBI are more frequent in children with head injury. AMS magnifies this effect. A symptom inventory is integral to the evaluation of mTBI in children; a smaller set of dichotomized symptoms may be as useful as and more easily administered than lengthier symptom scales.
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Affiliation(s)
- Joseph A Grubenhoff
- University of Colorado School of Medicine, Department of Pediatrics, Section of Emergency Medicine, Aurora, CO, USA.
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Berrigan L, Marshall S, McCullagh S, Velikonja D, Bayley M. Quality of clinical practice guidelines for persons who have sustained mild traumatic brain injury. Brain Inj 2011; 25:742-51. [DOI: 10.3109/02699052.2011.580317] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Faux S, Sheedy J, Delaney R, Riopelle R. Emergency department prediction of post-concussive syndrome following mild traumatic brain injury—an international cross-validation study. Brain Inj 2010; 25:14-22. [DOI: 10.3109/02699052.2010.531686] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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A Cognitive–Representational Approach to Patient Education After Mild Traumatic Brain Injury. Adv Emerg Nurs J 2010. [DOI: 10.1097/tme.0b013e3181e969a5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
PURPOSE OF REVIEW This review will examine mild closed head injury (CHI) and the current evidence on head computed tomography (CT) imaging risks in children, prediction rules to guide decisions on CT scan use, and issues of concussion after initial evaluation. RECENT FINDINGS The current literature offers preliminary evidence on the risks of radiation exposure from CT scans in children. A recent study introduces a validated prediction rule for use in mild CHI, to limit the number of CT scans performed. Concurrent with this progress, fast (or short sequence) MRI represents an emerging technology that may prove to be a viable alternative to CT scan use in certain cases of mild CHI where imaging is desired. The initial emergency department evaluation for mild CHI is the start point for a sequence of follow-up to assure that postconcussive symptoms fully resolve. The literature on sports-related concussion offers some information that may be used for patients with non-sports-related concussion. SUMMARY It is clear that CT scan use should be as safe and limited in scope as possible for children. Common decisions on the use of CT imaging for mild head injury can now be guided by a prediction rule for clinically important traumatic brain injury. Parameters for the follow-up care of patients with mild CHI after emergency department discharge are needed in the future to assure that postconcussive symptoms are adequately screened for full resolution.
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