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Ray S, Luke J, Kreitzer N. Patient-centered mild traumatic brain injury interventions in the emergency department. Am J Emerg Med 2024; 79:183-191. [PMID: 38460465 DOI: 10.1016/j.ajem.2024.02.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/21/2024] [Accepted: 02/25/2024] [Indexed: 03/11/2024] Open
Abstract
INTRODUCTION Traumatic brain injury (TBI) results in 2.5 million emergency department (ED) visits per year in the US, with mild traumatic brain injury (mTBI) accounting for 90% of cases. There is considerable evidence that many experience chronic symptoms months to years later. This population is rarely represented in interventional studies. Management of adult mTBI in the ED has remained unchanged, without consensus of therapeutic options. The aim of this review was to synthesize existing literature of patient-centered ED treatments for adults who sustain an mTBI, and to identify practices that may offer promise. METHODS A systematic review was conducted using the PubMed and Cochrane databases, while following PRISMA guidelines. Studies describing pediatric patients, moderate to severe TBI, or interventions outside the ED were excluded. Two reviewers independently performed title and abstract screening. A third blinded reviewer resolved discrepancies. The Mixed Methods Appraisal Tool (MMAT) was employed to assess the methodological quality of the studies. RESULTS Our search strategy generated 1002 unique titles. 95 articles were selected for full-text screening. The 26 articles chosen for full analysis were grouped into one of the following intervention categories: (1) predictive models for Post-Concussion Syndrome (PCS), (2) discharge instructions, (3) pharmaceutical treatment, (4) clinical protocols, and (5) functional assessment. Studies that implemented a predictive PCS model successfully identified patients at highest risk for PCS. Trials implementing discharge related interventions found the use of video discharge instructions, encouragement of daily light exercise or bed rest, and text messaging did not significantly reduce mTBI symptoms. The use of electronic clinical practice guidelines (eCPG) and longer leaves of absence from work following injury reduced symptoms. Ondansetron was shown to reduce nausea in mTBI patients. Studies implementing ED Observation Units found significant declines in inpatient admissions and length of hospital stay. The use of tablet-based tasks was found to be superior to many standard cognitive assessments. CONCLUSION Validated instruments are available to aid clinicians in identifying patients at risk for PCS or serious cognitive impairment. EDOU management and evidence-based modifications to discharge instructions may improve mTBI outcomes. Additional research is needed to establish the therapeutic value of medications and lifestyle changes for the treatment of mTBI in the ED.
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Affiliation(s)
- Sarah Ray
- University of Cincinnati School of Medicine, USA
| | - Jude Luke
- University of Cincinnati School of Medicine, USA
| | - Natalie Kreitzer
- Department of Emergency Medicine, University of Cincinnati, USA.
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Pei Y, Kemp AM, O'Brien KH. Investigating the Student in Returning to Learn After Concussion: A Systematic Review and Meta-Analysis. THE JOURNAL OF SCHOOL HEALTH 2023; 93:594-620. [PMID: 36852558 DOI: 10.1111/josh.13307] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 11/14/2022] [Accepted: 02/05/2023] [Indexed: 06/06/2023]
Abstract
PURPOSE Examine concussion effects on academic outcomes, including student perspectives. METHODS This study included a systematic review and meta-analysis examining post-concussion school attendance, academic performance, perceptions of academic difficulty, and accommodations for students in elementary through college settings. The analysis considered pre- and post-injury factors, along with injury factors that contribute to post-concussion academic outcomes. RESULTS The systematic review showed that students with concussion miss more school days and perceive higher levels of academic difficulty, but results about academic performance varied. Meta-analysis yielded small concussion effects on school absence and academic performance and moderate effects on perceptions of academic difficulty. Female sex, older age, history of migraine, prior concussions, severe or persistent symptoms, vestibular-ocular motor, and cognitive disruptions are risk factors, but these moderators were not identified in the meta-analysis due to lack of effect sizes. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY This study confirmed negative concussion effects on academic absences, performance, and perceptions of academic difficulty. Identified contributing factors will guide future practices to support students returning to learn after concussion. CONCLUSIONS Negative impacts to academics from concussion may be amplified by complicating factors. Future investigations are needed to confirm risk factors and mitigating effects of early identification and post-injury supports.
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Affiliation(s)
- Yalian Pei
- Communication Sciences and Special Education, University of Georgia, 110 Carlton Street, Athens, GA, 30602
| | - Amy M Kemp
- Communication Sciences and Special Education, University of Georgia, 110 Carlton Street, Athens, GA, 30602
| | - Katy H O'Brien
- Communication Sciences and Special Education, University of Georgia, 110 Carlton Street, Athens, GA 30602; Courage Kenny Rehabilitation Institute Allina Health, 800 E 28th St, Minneapolis, MN, 55407
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3
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Cancelliere C, Verville L, Stubbs JL, Yu H, Hincapié CA, Cassidy JD, Wong JJ, Shearer HM, Connell G, Southerst D, Howitt S, Guist B, Silverberg ND. Post-Concussion Symptoms and Disability in Adults with Mild Traumatic Brain Injury: A Systematic Review and Meta-Analysis. J Neurotrauma 2023. [PMID: 36472218 DOI: 10.1089/neu.2022.0185] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Studies investigating long-term symptoms and disability after mild traumatic brain injury (mTBI) have yielded mixed results. This systematic review and meta-analysis aimed to determine the prevalence of self-reported post-concussion symptoms (PCS) and disability following mTBI. We systematically searched MEDLINE, Embase, CINAHL, CENTRAL, and PsycInfo to identify inception cohort studies of adults with mTBI. Paired reviewers independently extracted data and assessed risk of bias with the Scottish Intercollegiate Guidelines Network criteria. We identified 43 eligible studies for the systematic review; 41 were rated as high risk of bias, primarily due to high attrition (> 20%). Twenty-one studies (49%) were included in the meta-analyses (five studies were narratively synthesized; 17 studies were duplicate reports). At 3-6 months post-injury, the estimated prevalence of PCS from random-effects meta-analyses was 31.3% (95% confidence interval [CI] = 25.4-38.4) using a lenient definition of PCS (2-4 mild severity PCS) and 18.3% (95% CI = 13.6-24.0) using a more stringent definition. The estimated prevalence of disability was 54.0% (95% CI = 49.4-58.6) and 29.6% (95% CI = 27.8-31.5) when defined as Glasgow Outcome Scale-Extended <8 and <7, respectively. The prevalence of symptoms similar to PCS was higher in adults with mTBI versus orthopedic injury (prevalence ratio = 1.57, 95% CI = 1.22-2.02). In a meta-regression, attrition rate was the only study-related factor significantly associated with higher estimated prevalence of PCS. Setting attrition to 0%, the estimated prevalence of PCS (lenient definition) was 16.1%. We conclude that nearly one in three adults who present to an emergency department or trauma center with mTBI report at least mild severity PCS 3-6 months later, but controlling for attrition bias, the true prevalence may be one in six. Studies with representative samples and high retention rates are needed.
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Affiliation(s)
- Carol Cancelliere
- Faculty of Health Sciences, Ontario Tech University, Ontario, Canada.,Institute for Disability and Rehabilitation Research, Ontario Tech University and Canadian Memorial Chiropractic College (CMCC), Ontario, Canada
| | - Leslie Verville
- Faculty of Health Sciences, Ontario Tech University, Ontario, Canada.,Institute for Disability and Rehabilitation Research, Ontario Tech University and Canadian Memorial Chiropractic College (CMCC), Ontario, Canada
| | - Jacob L Stubbs
- Department of Medicine, University of British Columbia, British Columbia, Canada
| | - Hainan Yu
- Faculty of Health Sciences, Ontario Tech University, Ontario, Canada.,Institute for Disability and Rehabilitation Research, Ontario Tech University and Canadian Memorial Chiropractic College (CMCC), Ontario, Canada
| | - Cesar A Hincapié
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland.,University Spine Centre Zurich (UWZH), Balgrist University Hospital and University of Zurich, Zurich, Switzerland
| | - J David Cassidy
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
| | - Jessica J Wong
- Faculty of Health Sciences, Ontario Tech University, Ontario, Canada.,Institute for Disability and Rehabilitation Research, Ontario Tech University and Canadian Memorial Chiropractic College (CMCC), Ontario, Canada
| | - Heather M Shearer
- Faculty of Health Sciences, Ontario Tech University, Ontario, Canada.,Institute for Disability and Rehabilitation Research, Ontario Tech University and Canadian Memorial Chiropractic College (CMCC), Ontario, Canada
| | - Gaelan Connell
- Faculty of Health Sciences, Ontario Tech University, Ontario, Canada.,Institute for Disability and Rehabilitation Research, Ontario Tech University and Canadian Memorial Chiropractic College (CMCC), Ontario, Canada
| | - Danielle Southerst
- Faculty of Health Sciences, Ontario Tech University, Ontario, Canada.,Institute for Disability and Rehabilitation Research, Ontario Tech University and Canadian Memorial Chiropractic College (CMCC), Ontario, Canada
| | - Scott Howitt
- Department of Clinical Education and Patient Care, Canadian Memorial Chiropractic College, Ontario, Canada
| | - Brett Guist
- Department of Undergraduate Education, Canadian Memorial Chiropractic College, Ontario, Canada
| | - Noah D Silverberg
- Department of Psychology, University of British Columbia, British Columbia, Canada
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4
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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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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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Mitchell G, Taylor J, Jin G, Snelling R. A review of minor traumatic brain injury presentations and their management in Brisbane emergency departments. JOURNAL OF CONCUSSION 2021. [DOI: 10.1177/20597002211006551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective A retrospective audit of minor traumatic brain injury presentations to three Brisbane emergency departments aiming to assess rates of CT scans and compliance with the Canadian CT Head Rule (CCTHR), as well as reviewing the demographics of patients and their management. Method Minor traumatic brain injury presentations to the Emergency departments of the Royal Brisbane and Women’s Hospital, Redcliffe Hospital and Queen Elizabeth II Hospital between July 1st and August 30th, 2019 were identified via diagnosis searches in patient tracking systems. Data collected included patient demographics, use of CT scans and Abbreviated Westmead Post Traumatic Amnesia Scale assessment, length of stay and discharge advice regarding return to sport. Results 200 minor traumatic brain injury presentations were included. 75% of patients received a CT head with only 9% of these found to be non-compliant with the CCTHR. The most common indications for CTs were age >65, GCS <15 at 2 hours post injury and anticoagulation. Only 40% of patients that qualified for A-WTPAS received the assessment. 18% of presentations were due to sporting injuries and 69% were not given return to play advice. The average length of stay was 250 minutes with 41.5% of presentations longer than 4 hours. 99% of the patients were discharged home from the ED with 1% admitted. Conclusion The study characterised minor traumatic brain injury management across three emergency departments and showed that most patients received CT head scans that were indicated. However, other areas of management such as A-WPTAs and return to play advice must be improved.
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Affiliation(s)
- Gary Mitchell
- Royal Brisbane and Women's Hospital Emergency and Trauma Centre, Herston QLD, Australia
| | - Jack Taylor
- Royal Brisbane and Women's Hospital Emergency and Trauma Centre, Herston QLD, Australia
| | - Gilbert Jin
- Redcliffe Hospital Emergency Department, Redcliffe QLD, Australia
| | - Rahul Snelling
- Royal Brisbane and Women's Hospital Emergency and Trauma Centre, Herston QLD, Australia
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7
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Sharma A, Muresanu DF, Sahib S, Tian ZR, Castellani RJ, Nozari A, Lafuente JV, Buzoianu AD, Bryukhovetskiy I, Manzhulo I, Patnaik R, Wiklund L, Sharma HS. Concussive head injury exacerbates neuropathology of sleep deprivation: Superior neuroprotection by co-administration of TiO 2-nanowired cerebrolysin, alpha-melanocyte-stimulating hormone, and mesenchymal stem cells. PROGRESS IN BRAIN RESEARCH 2020; 258:1-77. [PMID: 33223033 DOI: 10.1016/bs.pbr.2020.09.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Sleep deprivation (SD) is common in military personnel engaged in combat operations leading to brain dysfunction. Military personnel during acute or chronic SD often prone to traumatic brain injury (TBI) indicating the possibility of further exacerbating brain pathology. Several lines of evidence suggest that in both TBI and SD alpha-melanocyte-stimulating hormone (α-MSH) and brain-derived neurotrophic factor (BDNF) levels decreases in plasma and brain. Thus, a possibility exists that exogenous supplement of α-MSH and/or BDNF induces neuroprotection in SD compounded with TBI. In addition, mesenchymal stem cells (MSCs) are very portent in inducing neuroprotection in TBI. We examined the effects of concussive head injury (CHI) in SD on brain pathology. Furthermore, possible neuroprotective effects of α-MSH, MSCs and neurotrophic factors treatment were explored in a rat model of SD and CHI. Rats subjected to 48h SD with CHI exhibited higher leakage of BBB to Evans blue and radioiodine compared to identical SD or CHI alone. Brain pathology was also exacerbated in SD with CHI group as compared to SD or CHI alone together with a significant reduction in α-MSH and BDNF levels in plasma and brain and enhanced level of tumor necrosis factor-alpha (TNF-α). Exogenous administration of α-MSH (250μg/kg) together with MSCs (1×106) and cerebrolysin (a balanced composition of several neurotrophic factors and active peptide fragments) (5mL/kg) significantly induced neuroprotection in SD with CHI. Interestingly, TiO2 nanowired delivery of α-MSH (100μg), MSCs, and cerebrolysin (2.5mL/kg) induced enhanced neuroprotection with higher levels of α-MSH and BDNF and decreased the TNF-α in SD with CHI. These observations are the first to show that TiO2 nanowired administration of α-MSH, MSCs and cerebrolysin induces superior neuroprotection following SD in CHI, not reported earlier. The clinical significance of our findings in light of the current literature is discussed.
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Affiliation(s)
- Aruna Sharma
- International Experimental Central Nervous System Injury & Repair (IECNSIR), Department of Surgical Sciences, Anesthesiology & Intensive Care Medicine, Uppsala University Hospital, Uppsala University, Uppsala, Sweden.
| | - Dafin F Muresanu
- Department of Clinical Neurosciences, University of Medicine & Pharmacy, Cluj-Napoca, Romania; "RoNeuro" Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania
| | - Seaab Sahib
- Department of Chemistry & Biochemistry, University of Arkansas, Fayetteville, AR, United States
| | - Z Ryan Tian
- Department of Chemistry & Biochemistry, University of Arkansas, Fayetteville, AR, United States
| | - Rudy J Castellani
- Department of Pathology, University of Maryland, Baltimore, MD, United States
| | - Ala Nozari
- Anesthesiology & Intensive Care, Massachusetts General Hospital, Boston, MA, United States
| | - José Vicente Lafuente
- LaNCE, Department of Neuroscience, University of the Basque Country (UPV/EHU), Leioa, Bizkaia, Spain
| | - Anca D Buzoianu
- Department of Clinical Pharmacology and Toxicology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Igor Bryukhovetskiy
- Department of Fundamental Medicine, School of Biomedicine, Far Eastern Federal University, Vladivostok, Russia; Laboratory of Pharmacology, National Scientific Center of Marine Biology, Far East Branch of the Russian Academy of Sciences, Vladivostok, Russia
| | - Igor Manzhulo
- Department of Fundamental Medicine, School of Biomedicine, Far Eastern Federal University, Vladivostok, Russia; Laboratory of Pharmacology, National Scientific Center of Marine Biology, Far East Branch of the Russian Academy of Sciences, Vladivostok, Russia
| | - Ranjana Patnaik
- Department of Biomaterials, School of Biomedical Engineering, Indian Institute of Technology, Banaras Hindu University, Varanasi, India
| | - Lars Wiklund
- International Experimental Central Nervous System Injury & Repair (IECNSIR), Department of Surgical Sciences, Anesthesiology & Intensive Care Medicine, Uppsala University Hospital, Uppsala University, Uppsala, Sweden
| | - Hari Shanker Sharma
- International Experimental Central Nervous System Injury & Repair (IECNSIR), Department of Surgical Sciences, Anesthesiology & Intensive Care Medicine, Uppsala University Hospital, Uppsala University, Uppsala, Sweden.
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8
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Mehrolhassani N, Movahedi M, Nazemi-Rafi M, Mirafzal A. Persistence of post-concussion symptoms in patients with mild traumatic brain injury and no psychiatric history in the emergency department. Brain Inj 2020; 34:1350-1357. [PMID: 32772732 DOI: 10.1080/02699052.2020.1802659] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE To elucidate the predictive factors for persistent post-concussion symptoms at 1 and 3 months following minor traumatic brain injuries (mTBIs) in patients with no psychiatric history. METHODS This was an observational study in an academic trauma centre including adult patients with a history of mTBI and no psychiatric history. Exclusion criteria were missing the follow-up phone calls, radiologic abnormalities, simultaneous injuries and refusal to participate. Outcomes were post-concussion syndrome according to the international classification of diseases (ICD)-10 (ICD-PCS) and persistence of more than one mTBI related symptoms at 1 and 3 months post-injury. RESULTS From 364 enrolled patients, 16 (4.4%) developed ICD-PCS, whereas 28 (7.6%) and 8(2.1%) reported more than one symptom at one and three months, respectively. Multivariable analysis showed associations between ICD-PCS with more than one initial symptom in the emergency department (ED) and the non-motor vehicle collision (non-MVC) impact mechanism with area under curve of 0.77. The former variable was associated with the persistence of more than one post-concussion symptom at one and three months. CONCLUSION More than one symptom in the ED and the mechanism of injury not related to MVCs (sports, violence or fall injuries) may predict symptom persistence. Early treatment and follow-up strategies may be beneficial for vulnerable patients.
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Affiliation(s)
- Narges Mehrolhassani
- Department of Emergency Medicine, Kerman University of Medical Sciences , Kerman, Iran
| | - Mitra Movahedi
- Department of Emergency Medicine, Kerman University of Medical Sciences , Kerman, Iran
| | - Masoomeh Nazemi-Rafi
- Department of Emergency Medicine, Kerman University of Medical Sciences , Kerman, Iran
| | - Amirhossein Mirafzal
- Department of Emergency Medicine, Kerman University of Medical Sciences , Kerman, Iran
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Abdul Rahman N'I, Nurumal MS, Awang MS, Mohd Shah ANS. Emergency department discharge instruction for mild traumatic brain injury: Evaluation on readability, understandability, actionability and content. Australas Emerg Care 2020; 23:240-246. [PMID: 32713770 DOI: 10.1016/j.auec.2020.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 05/31/2020] [Accepted: 06/20/2020] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Emergency departments (EDs) routinely provide discharge instructions due to a large number of patients with mild traumatic brain injury (mTBI) being discharged home directly from ED. This study aims to evaluate the quality of available mTBI discharge instructions provided by EDs of Malaysia government hospitals. METHODS All 132 EDs were requested for a copy of written discharge instruction given to the patients. The mTBI discharge instructions were evaluated using the Patient Education Materials Assessment-Printable Tool (PEMAT-P) for understandability and actionability. Readability was measured using an online readability tool of Malay text. The content was compared against the discharge instructions recommended by established guidelines. RESULTS 49 articles were eligible for the study. 26 of the articles met the criteria of understandability, and 3 met the criteria for actionability. The average readability level met the ability of average adult. Most of the discharge instructions focused on emergency symptoms, and none contained post-concussion features. CONCLUSION Majority of the discharge instructions provided were appropriate for average people to read but difficult to understand and act upon. Important information was neglected in most discharge instructions. Thus, revision and future development of mTBI discharge instruction should consider health literacy demand and cognitive ability to process such information.
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Affiliation(s)
- Nurul 'Inayati Abdul Rahman
- Department of Critical Care Nursing, Kulliyyah (Faculty) of Nursing, International Islamic University Malaysia, 25200 Kuantan, Pahang, Malaysia.
| | - Mohd Said Nurumal
- Department of Critical Care Nursing, Kulliyyah (Faculty) of Nursing, International Islamic University Malaysia, 25200 Kuantan, Pahang, Malaysia
| | - Mohamed Saufi Awang
- Neurosurgery Unit, Department of Surgery, Kulliyyah (Faculty) of Medicine, International Islamic University Malaysia, 25200 Kuantan, Pahang, Malaysia
| | - Aida Nur Sharini Mohd Shah
- Department of Internal Medicine, Kulliyyah (Faculty) of Medicine, International Islamic University Malaysia, 25200 Kuantan, Pahang, Malaysia
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10
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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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11
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Lin SH, Wong BS, Chen CW, Lin SC, Lin YT. Follow-up of patients subject to the mild traumatic brain injury. FORMOSAN JOURNAL OF SURGERY 2020. [DOI: 10.4103/fjs.fjs_111_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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12
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Korley FK, Peacock WF, Eckner JT, Maio R, Levin S, Bechtold KT, Peters M, Roy D, Falk HJ, Hall AJ, Van Meter TE, Gonzalez R, Diaz‐Arrastia R. Clinical Gestalt for Early Prediction of Delayed Functional and Symptomatic Recovery From Mild Traumatic Brain Injury Is Inadequate. Acad Emerg Med 2019; 26:1384-1387. [PMID: 31397520 DOI: 10.1111/acem.13844] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 08/03/2019] [Accepted: 08/04/2019] [Indexed: 12/01/2022]
Affiliation(s)
| | - W. Frank Peacock
- Department of Emergency Medicine Baylor College of Medicine Houston TX
| | - James T. Eckner
- Department of Physical Medicine & Rehabilitation University of Michigan Medical School University of Michigan Ann Arbor MI
| | - Ronald Maio
- Department of Emergency Medicine University of Michigan Ann Arbor MI
| | - Scott Levin
- Department of Emergency Medicine Johns Hopkins School of Medicine Baltimore MD
| | - Kathleen T. Bechtold
- Department of Physical Medicine & Rehabilitation Johns Hopkins School of Medicine Baltimore MD
| | - Matthew Peters
- Department of Psychiatry and Behavioral Sciences Johns Hopkins School of Medicine Baltimore MD
| | - Durga Roy
- Department of Psychiatry and Behavioral Sciences Johns Hopkins School of Medicine Baltimore MD
| | - Hayley J. Falk
- Department of Emergency Medicine University of Michigan Ann Arbor MI
| | - Anna J. Hall
- Department of Emergency Medicine Johns Hopkins School of Medicine Baltimore MD
| | | | - Richard Gonzalez
- Institute for Social Research University of Michigan Ann Arbor MI
| | - Ramon Diaz‐Arrastia
- Department of Neurology University of Pennsylvania Perelman School of Medicine Penn Presbyterian Medical Center Philadelphia PA
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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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Navratilova E, Rau J, Oyarzo J, Tien J, Mackenzie K, Stratton J, Remeniuk B, Schwedt T, Anderson T, Dodick D, Porreca F. CGRP-dependent and independent mechanisms of acute and persistent post-traumatic headache following mild traumatic brain injury in mice. Cephalalgia 2019; 39:1762-1775. [DOI: 10.1177/0333102419877662] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background Acute and persistent post-traumatic headache are often debilitating consequences of traumatic brain injury. Underlying physiological mechanisms of post-traumatic headache and its persistence remain unknown, and there are currently no approved therapies for these conditions. Post-traumatic headache often presents with a migraine-like phenotype. As calcitonin-gene related peptide promotes migraine headache, we explored the efficacy and timing of intervention with an anti- calcitonin-gene related peptide monoclonal antibody in novel preclinical models of acute post-traumatic headache and persistent post-traumatic headache following a mild traumatic brain injury event in mice. Methods Male, C57Bl/6 J mice received a sham procedure or mild traumatic brain injury resulting from a weight drop that allowed free head rotation while under minimal anesthesia. Periorbital and hindpaw tactile stimulation were used to assess mild traumatic brain injury-induced cutaneous allodynia. Two weeks after the injury, mice were challenged with stress, a common aggravator of migraine and post-traumatic headache, by exposure to bright lights (i.e. bright light stress) and cutaneous allodynia was measured hourly for 5 hours. A murine anti- calcitonin-gene related peptide monoclonal antibody was administered after mild traumatic brain injury at different time points to allow evaluation of the consequences of either early and sustained calcitonin-gene related peptide sequestration or late administration only prior to bright light stress. Results Mice with mild traumatic brain injury, but not a sham procedure, exhibited both periorbital and hindpaw cutaneous allodynia that resolved by post-injury day 13. Following resolution of injury-induced cutaneous allodynia, exposure to bright light stress re-instated periorbital and hindpaw cutaneous allodynia in injured, but not sham mice. Repeated administration of anti-calcitonin-gene related peptide monoclonal antibody at 2 hours, 7 and 14 days post mild traumatic brain injury significantly attenuated the expression of cutaneous allodynia when evaluated over the 14-day post injury time course and also prevented bright light stress-induced cutaneous allodynia in injured mice. Administration of anti-calcitonin-gene related peptide monoclonal antibody only at 2 hours and 7 days after mild traumatic brain injury blocked injury-induced cutaneous allodynia and partially prevented bright light stress-induced cutaneous allodynia. A single administration of anti-calcitonin-gene related peptide monoclonal antibody after the resolution of the peak injury-induced cutaneous allodynia, but prior to bright light stress challenge, did not prevent bright light stress-induced cutaneous allodynia. Conclusions We used a clinically relevant mild traumatic brain injury event in mice along with a provocative stimulus as novel models of acute post-traumatic headache and persistent post-traumatic headache. Following mild traumatic brain injury, mice demonstrated transient periorbital and hindpaw cutaneous allodynia suggestive of post-traumatic headache-related pain and establishment of central sensitization. Following resolution of injury-induced cutaneous allodynia, exposure to bright light stress re-established cutaneous allodynia, suggestive of persistent post-traumatic headache-related pain. Continuous early sequestration of calcitonin-gene related peptide prevented both acute post-traumatic headache and persistent post-traumatic headache. In contrast, delayed anti-calcitonin-gene related peptide monoclonal antibody treatment following establishment of central sensitization was ineffective in preventing persistent post-traumatic headache. These observations suggest that mechanisms involving calcitonin-gene related peptide underlie the expression of acute post-traumatic headache, and drive the development of central sensitization, increasing vulnerability to headache triggers and promoting persistent post-traumatic headache. Early and continuous calcitonin-gene related peptide blockade following mild traumatic brain injury may represent a viable treatment option for post-traumatic headache and for the prevention of post-traumatic headache persistence. Abbreviations CA Cutaneous allodynia CGRP Calcitonin gene-related peptide mTBI Mild traumatic brain injury PTH Post-traumatic headache APTH Acute post-traumatic headache PPTH Persistent post-traumatic headache
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Affiliation(s)
- Edita Navratilova
- Department of Pharmacology, Arizona Health Sciences Center, University of Arizona, Tucson, AZ, USA
| | - Jill Rau
- Mayo Clinic, Scottsdale, AZ, USA
| | | | | | | | | | - Bethany Remeniuk
- Department of Pharmacology, Arizona Health Sciences Center, University of Arizona, Tucson, AZ, USA
| | | | - Trent Anderson
- Department of Basic Medical Sciences, University of Arizona College of Medicine, Phoenix, AZ, USA
| | | | - Frank Porreca
- Department of Pharmacology, Arizona Health Sciences Center, University of Arizona, Tucson, AZ, USA
- Mayo Clinic, Scottsdale, AZ, USA
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15
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Schackow L, Lape JE. Mild brain injury education: preparing the caregiver. INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2019. [DOI: 10.12968/ijtr.2018.0040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background/Aim The purpose of this pre-test, post-test study was to determine if caregivers of patients diagnosed with a mild brain injury feel better prepared for the caregiving role following a single, individualised education session in the acute care hospital setting. Methods A total of 17 patients and 21 caregivers were recruited. A pre-intervention survey was used to gather baseline perceptions on preparedness, worry, and brain injury knowledge. The intervention included a review of a mild brain injury educational booklet and a caregiver handout with the patient and caregiver during a 45–60-minute session. A post-intervention survey was used to assess caregivers' perceptions following the educational session. Findings The mean Likert survey responses of the caregivers indicated an improvement in the areas of worry, preparedness for caregiving, and understanding of brain injury post-intervention. Caregivers unanimously agreed that their understanding of brain injury and ability to manage the patients' symptoms was a direct result of the intervention. Conclusions The findings from this pilot study demonstrate the benefits of a single educational session with caregivers in the hospital setting. Exploring if the educational material was used by caregivers post-discharge is warranted to further support the results.
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Affiliation(s)
- LeAnn Schackow
- Occupational Therapist, Parkview Regional Medical Center, Fort Wayne, Indiana, US
| | - Jennifer E Lape
- Associate Professor of Occupational Therapy, Chatham University, Pittsburgh, Pennsylvania, US
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16
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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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17
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Studerus-Germann AM, Gautschi OP, Bontempi P, Thiran JP, Daducci A, Romascano D, von Ow D, Hildebrandt G, von Hessling A, Engel DC. Central nervous system microbleeds in the acute phase are associated with structural integrity by DTI one year after mild traumatic brain injury: A longitudinal study. Neurol Neurochir Pol 2018; 52:710-719. [PMID: 30245171 DOI: 10.1016/j.pjnns.2018.08.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 08/31/2018] [Accepted: 08/31/2018] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Several imaging modalities are under investigation to unravel the pathophysiological mystery of delayed performance deficits in patients after mild traumatic brain injury (mTBI). Although both imaging and neuropsychological studies have been conducted, only few data on longitudinal correlations of diffusion tensor imaging (DTI), susceptibility weighted imaging (SWI) and extensive neuropsychological testing exist. METHODS MRI with T1- and T2-weighted, SWI and DTI sequences at baseline and 12 months of 30 mTBI patients were compared with 20 healthy controls. Multiparametric assessment included neuropsychological testing of cognitive performance and post-concussion syndrome (PCS) at baseline, 3 and 12 months post-injury. Data analysis encompassed assessment of cerebral microbleeds (Mb) in SWI, tract-based spatial statistics (TBSS) and voxel-based morphometry (VBM) of DTI (VBM-DTI). Imaging markers were correlated with neuropsychological testing to evaluate sensitivity to cognitive performance and post-concussive symptoms. RESULTS Patients with Mb in SWI in the acute phase showed worse performance in several cognitive tests at baseline and in the follow-ups during the chronic phase and higher symptom severity in the post concussion symptom scale (PCSS) at twelve months post-injury. In the acute phase there was no statistical difference in structural integrity as measured with DTI between mTBI patients and healthy controls. At twelve months post-injury, loss of structural integrity in mTBI patients was found in nearly all DTI indices compared to healthy controls. CONCLUSIONS Presence of Mb detected by SWI was associated with worse cognitive outcome and persistent PCS in mTBI patients, while DTI did not prove to predict neuropsychological outcome in the acute phase.
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Affiliation(s)
- Aline M Studerus-Germann
- Division of Neuropsychology, Department of Neurology, Cantonal Hospital, St. Gallen, Switzerland; Department of Psychopathology and Clinical Intervention, University of Zurich, Switzerland
| | - Oliver P Gautschi
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland; Department of Neurosurgery, Geneva University Medical Center, Faculty of Medicine, University of Geneva, Switzerland
| | | | - Jean-Philippe Thiran
- Signal Processing Laboratory (LTS5), Ecole Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Alessandro Daducci
- Signal Processing Laboratory (LTS5), Ecole Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - David Romascano
- Signal Processing Laboratory (LTS5), Ecole Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Dieter von Ow
- Emergency Department, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Gerhard Hildebrandt
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Alexander von Hessling
- Department of Radiology and Nuclear Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland; Department of Radiology and Nuclear Medicine, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Doortje C Engel
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland; Department of Neurosurgery, University Hospital Tübingen, Tübingen, Germany.
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18
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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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19
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Fotakopoulos G, Makris D, Tsianaka E, Kotlia P, Karakitsios P, Gatos C, Tzannis A, Fountas K. The value of the identification of predisposing factors for post-traumatic amnesia in management of mild traumatic brain injury. Brain Inj 2018; 32:563-568. [PMID: 29400569 DOI: 10.1080/02699052.2018.1432075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECT To identify the risk factors for post-traumatic amnesia (PTA) and to document the incidence of PTA after mild traumatic brain injuries. METHODS This was a prospective study, affecting mild TBI (mTBI) (Glasgow Coma Scale 14-15) cases attending to the Emergency Department between January 2009 and April 2012 (40 months duration). Patients were divided into two groups (Group A: without PTA, and Group B: with PTA, and they were assessed according to the risk factors. RESULTS A total of 1762 patients (males: 1002, 56.8%) were meeting study inclusion criteria [Group A: n = 1678 (83.8%), Group B: n = 84 (4.2%)]. Age, CT findings: (traumatic focal HCs in the frontal and temporal lobes or more diffuse punctate HCs, and skull base fractures), anticoagulation therapy and seizures were independent factors of PTA. There was no statistically significant correlation between PTA and sex, convexity fractures, stroke event, mechanism of mTBI (fall +/or beating), hypertension, coronary heart disease, chronic smokers and diabetes (p > 0.005). CONCLUSION CT findings: (traumatic focal HCs in the frontal and temporal lobes or more diffuse punctate HCs and skull base fractures), age, seizures and anticoagulation/antiplatelet therapy, were independent factors of PTA and could be used as predictive factors after mTBI.
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Affiliation(s)
- George Fotakopoulos
- a Department of Neurosurgery , University Hospital of Thessaly, University Hospital of Larissa , Thessaly , Greece
| | - Demosthenes Makris
- b Department of Head of Critical Care , University Hospital of Larissa , Larissa , Greece
| | - Eleni Tsianaka
- a Department of Neurosurgery , University Hospital of Thessaly, University Hospital of Larissa , Thessaly , Greece
| | - Polikceni Kotlia
- b Department of Head of Critical Care , University Hospital of Larissa , Larissa , Greece
| | - Paulos Karakitsios
- c Department of General Medicine , Public Health System of Palamas , Palamas , Greece
| | - Charalabos Gatos
- a Department of Neurosurgery , University Hospital of Thessaly, University Hospital of Larissa , Thessaly , Greece
| | - Alkiviadis Tzannis
- a Department of Neurosurgery , University Hospital of Thessaly, University Hospital of Larissa , Thessaly , Greece
| | - Kostas Fountas
- a Department of Neurosurgery , University Hospital of Thessaly, University Hospital of Larissa , Thessaly , Greece
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20
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Galili SF, Bech BH, Vestergaard C, Fenger-Gron M, Christensen J, Vestergaard M, Ahrensberg J. Use of general practice before and after mild traumatic brain injury: a nationwide population-based cohort study in Denmark. BMJ Open 2017; 7:e017735. [PMID: 29248884 PMCID: PMC5778290 DOI: 10.1136/bmjopen-2017-017735] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 09/02/2017] [Accepted: 10/03/2017] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES Traumatic brain injury (TBI) is commonly seen in the emergency department (ED). Approximately 85%-90% of TBIs are mild (mTBI). Some cause symptoms such as headache, dizziness, anxiety, blurred vision, insomnia and concentration difficulties, collectively known as postconcussion syndrome (PCS). Some studies suggest that recovery from mTBI is complete. Others find that symptoms persist for months, even years. The aim of this study was to describe the use of general practice, before and after mTBI, as a proxy for symptoms in a large cohort. DESIGN Nationwide population-based matched cohort study. SETTING Danish EDs and general practice. PARTICIPANTS All patients (aged ≥18 years), first-time diagnosed with mTBI in a Danish ED between 1 January 1998 and 31 December 2010 (n=93 517). Ten reference persons per patient with mTBI were randomly matched on gender, age and general practice (n=935 170). PRIMARY OUTCOME Overall use of general practice; consultations relating to mental and physical health. RESULTS We found higher use of general practice during the first year after mTBI for all ages, both genders and all types of contacts. Age 18-40 years: women, incidence rate ratio (IRR) 1.59 (95% CI 1.57 to 1.61); men, IRR 1.82 (95% CI 1.80 to 1.85). Age 41-65 years: women, IRR 1.75 (95% CI 1.72 to 1.78); men, IRR 1.85(95% CI 1.82 to 1.89). Age 66+ years: women, IRR 1.55 (95% CI 1.52 to 1.58); men, IRR 1.55 (95% CI 1.51 to 1.59). After the first year, the use decreased to the level before mTBI. Individuals with mTBI and higher use of general practice before mTBI had lower socioeconomic status and more comorbidities (P<0.001). CONCLUSIONS The use of general practice was higher in the first year after mTBI, specifically in the first 3 months. Patients with mTBI had different healthcare-seeking behaviour several years before diagnosis than their matched reference persons. Pretraumatic morbidity should be considered in the evaluation of PCS.
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Affiliation(s)
- Stine Fjendbo Galili
- Department of Public Health, Research Unit for General Practice, Aarhus University, Aarhus, Denmark
| | - Bodil Hammer Bech
- Department of Public Health, Research Unit for General Practice and Section for Epidemiology, Aarhus University, Aarhus, Denmark
| | - Claus Vestergaard
- Department of Public Health, Research Unit for General Practice, Aarhus University, Aarhus, Denmark
| | - Morten Fenger-Gron
- Department of Public Health, Research Unit for General Practice, Aarhus University, Aarhus, Denmark
| | - Jakob Christensen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Mogens Vestergaard
- Department of Public Health, Research Unit for General Practice, Aarhus University, Aarhus, Denmark
| | - Jette Ahrensberg
- Department of Clinical Medicine, Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
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21
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Nelson LD, Furger RE, Ranson J, Tarima S, Hammeke TA, Randolph C, Barr WB, Guskiewicz K, Olsen CM, Lerner EB, McCrea MA. Acute Clinical Predictors of Symptom Recovery in Emergency Department Patients with Uncomplicated Mild Traumatic Brain Injury or Non-Traumatic Brain Injuries. J Neurotrauma 2017; 35:249-259. [PMID: 29017409 DOI: 10.1089/neu.2017.4988] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
There is a subset of patients with mild traumatic brain injury (mTBI) who report persistent symptoms that impair their functioning and quality of life. Being able to predict which patients will experience prolonged symptom recovery would help clinicians target resources for clinical follow-up to those most in need, and would facilitate research to develop precision medicine treatments for mTBI. The purpose of this study was to investigate the predictors of symptom recovery in a prospective sample of emergency department trauma patients with either mTBI or non-mTBI injuries. Subjects were examined at several time points from within 72 h to 45 days post-injury. We quantified and compared the value of a variety of demographic, injury, and clinical assessment (symptom, neurocognitive) variables for predicting self-reported symptom duration in both mTBI (n = 89) and trauma control (n = 73) patients. Several injury-related and neuropsychological variables assessed acutely (< 72 h) post-injury predicted symptom duration, particularly loss of consciousness (mTBI group), acute somatic symptom burden (both groups), and acute reaction time (both groups), with reasonably good model fit when including all of these variables (area under the receiver operating characteristic curve [AUC] = 0.76). Incorporating self-reported litigation involvement modestly increased prediction further (AUC = 0.80). The results highlight the multifactorial nature of mTBI recovery, and injury recovery more generally, and the need to incorporate a variety of variables to achieve adequate prediction. Further research to improve this model and validate it in new and more diverse trauma samples will be useful to build a neurobiopsychosocial model of recovery that informs treatment development.
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Affiliation(s)
- Lindsay D Nelson
- 1 Department of Neurosurgery and Neuroscience Research Center, Medical College of Wisconsin , Milwaukee, Wisconsin.,2 Department of Neurology, Medical College of Wisconsin , Milwaukee, Wisconsin
| | - Robyn E Furger
- 1 Department of Neurosurgery and Neuroscience Research Center, Medical College of Wisconsin , Milwaukee, Wisconsin
| | - Jana Ranson
- 1 Department of Neurosurgery and Neuroscience Research Center, Medical College of Wisconsin , Milwaukee, Wisconsin
| | - Sergey Tarima
- 3 Division of Biostatistics, Medical College of Wisconsin , Milwaukee, Wisconsin
| | - Thomas A Hammeke
- 4 Department of Psychiatry, Medical College of Wisconsin , Milwaukee, Wisconsin
| | | | - William B Barr
- 6 Department of Neurology, New York University School of Medicine , New York, New York
| | - Kevin Guskiewicz
- 7 Departments of Exercise and Sport Science & Orthopedics, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina
| | - Christopher M Olsen
- 8 Neuroscience Research Center and Department of Pharmacology and Toxicology, Medical College of Wisconsin , Milwaukee, Wisconsin
| | - E Brooke Lerner
- 9 Department of Emergency Medicine, Medical College of Wisconsin , Milwaukee, Wisconsin
| | - Michael A McCrea
- 1 Department of Neurosurgery and Neuroscience Research Center, Medical College of Wisconsin , Milwaukee, Wisconsin.,2 Department of Neurology, Medical College of Wisconsin , Milwaukee, Wisconsin
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22
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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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23
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Patrick SP, Gaudet LA, Krebs LD, Chambers T, Rowe BH. Emergency Physician Training on Mild Traumatic Brain Injury: A Systematic Review. AEM EDUCATION AND TRAINING 2017; 1:346-356. [PMID: 30051054 PMCID: PMC6001600 DOI: 10.1002/aet2.10053] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 07/14/2017] [Accepted: 07/19/2017] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Mild traumatic brain injury (mTBI) is the most common emergency department (ED) brain injury presentation worldwide. Despite its frequency, practice variation and care gaps exist among emergency physicians (EPs) in diagnosing and appropriately managing mTBI in the ED. The objective of this review was to identify mTBI-specific training undertaken to improve the detection and management of mTBIs by EPs and its impact on practice. METHODS A comprehensive search strategy utilized four bibliographic databases, the gray literature and the keywords concussion, mild traumatic brain injury, medical education, and continuing medical education (CME). To be included, studies were required to report on mTBI training received by practicing EPs at any point during their medical education or career. Studies examining clinical practice guidelines or use of diagnostic tools without active implementation or formal training were not included. Two reviewers screened unique citations for relevance and reviewed the full texts of relevant articles. Two independent researchers extracted data and assessed methodologic quality. At all stages, a third independent reviewer adjudicated discrepancies. RESULTS Overall, five studies were included from 409 unique results. None of the included studies were of high quality. Identified training on mTBI consisted of three training toolkits, conference presentations and academic journal articles, and pediatric fellowship training. Training primarily occurred as CME and focused on awareness of and management of mTBI; three studies reported physician practice changes, including increases in the use of evidence-based return-to-school and return-to-activity recommendations. CONCLUSIONS The few studies identified addressing mTBI training targeting EPs demonstrate the limited attention given to this issue. The current evidence-to-practice gap in mTBI management places patients at risk for suboptimal care in the ED, and existing mTBI knowledge translation, including education, requires optimization to effectively address the current gap in evidence-based practice for mTBI diagnosis and management in the ED.
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Affiliation(s)
- Sean P. Patrick
- Faculty of MedicineUniversity of OttawaOttawaONCanada
- Department of Emergency MedicineUniversity of AlbertaEdmontonABCanada
| | - Lindsay A. Gaudet
- Department of Emergency MedicineUniversity of AlbertaEdmontonABCanada
| | - Lynette D. Krebs
- Department of Emergency MedicineUniversity of AlbertaEdmontonABCanada
| | - Thane Chambers
- J. W. Scott Health Sciences LibraryUniversity of AlbertaEdmontonABCanada
| | - Brian H. Rowe
- Department of Emergency MedicineUniversity of AlbertaEdmontonABCanada
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24
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DuPrey KM, Webner D, Lyons A, Kucuk CH, Ellis JT, Cronholm PF. Convergence Insufficiency Identifies Athletes at Risk of Prolonged Recovery From Sport-Related Concussion. Am J Sports Med 2017; 45:2388-2393. [PMID: 28511593 DOI: 10.1177/0363546517705640] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Sensitive and specific screening methods are needed to identify athletes at risk of prolonged recovery after sport-related concussion (SRC). Convergence insufficiency (CI) is a common finding in concussed athletes. PURPOSE To assess the relationship between CI and recovery after SRC at the initial office visit. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS In this retrospective cohort study, 270 athletes (147 male, 123 female), mean ± SD age 14.7 ± 2.0 years (range, 10-21 years), with the diagnosis of SRC who presented for initial office visit between January 2014 and January 2016 were evaluated for near point of convergence (NPC). The athletes were categorized into 2 groups: normal near point of convergence (NPC ≤6 cm), and convergence insufficiency (NPC >6 cm). These athletes were then followed to determine recovery time. RESULTS Athletes presented for initial office visit at a mean of 5.2 ± 4.2 days (range, 1-21 days) after SRC. Half of the athletes had CI after SRC (50.4%; n = 136). Athletes with CI (NPC 12.3 ± 4.7 cm) took significantly longer to recover after SRC, requiring 51.6 ± 53.9 days, compared with athletes with normal NPC (4.1 ± 1.3 cm), who required 19.2 ± 14.7 days ( P < .001). After controlling for potential confounding variables, CI significantly increased the odds of prolonged recovery (≥28 days from injury) by 12.3-fold ( P < .001; 95% confidence interval, 6.6-23.0). CI screening correctly classified 75.2% of our sample with 84.2% sensitivity and 70.0% specificity. The positive predictive value for CI and prolonged recovery was 62.5%, and the negative predictive value was 88.1%. CONCLUSION CI at the initial office visit identified athletes at increased risk of prolonged recovery after SCR. Clinicians should consider measuring NPC in concussed athletes as a quick and inexpensive prognostic screening method.
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Affiliation(s)
- Kevin M DuPrey
- Department of Sports Medicine, Crozer-Keystone Health System, Springfield, Pennsylvania, USA
| | - David Webner
- Department of Sports Medicine, Crozer-Keystone Health System, Springfield, Pennsylvania, USA
| | - Adam Lyons
- Department of Family and Community Health, Center for Public Health Initiatives, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Crystal H Kucuk
- Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, USA
| | - Jeffrey T Ellis
- Department of Sports Medicine, Crozer-Keystone Health System, Springfield, Pennsylvania, USA
| | - Peter F Cronholm
- Department of Family and Community Health, Center for Public Health Initiatives, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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25
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Hides JA, Franettovich Smith MM, Mendis MD, Smith NA, Cooper AJ, Treleaven J, Leung F, Gardner AJ, McCrory P, Low Choy NL. A prospective investigation of changes in the sensorimotor system following sports concussion. An exploratory study. Musculoskelet Sci Pract 2017; 29:7-19. [PMID: 28259770 DOI: 10.1016/j.msksp.2017.02.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 02/10/2017] [Accepted: 02/16/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Sports concussion is a risk for players involved in high impact, collision sports. Post-concussion, the majority of symptoms subside within 7-10 days, but can persist in 10-20% of athletes. Understanding the effects of sports concussion on sensorimotor systems could inform physiotherapy treatment. OBJECTIVE To explore changes in sensorimotor function in the acute phase following sports concussion. DESIGN Prospective cohort study. METHODS Fifty-four players from elite rugby union and league teams were assessed at the start of the playing season. Players who sustained a concussion were assessed three to five days later. Measures included assessments of balance (sway velocity), vestibular system function (vestibular ocular reflex gain; right-left asymmetry), cervical proprioception (joint position error) and trunk muscle size and function. RESULTS During the playing season, 14 post-concussion assessments were performed within 3-5 days of injury. Significantly decreased sway velocity and increased size/contraction of trunk muscles, were identified. Whilst not significant overall, large inter-individual variation of test results for cervical proprioception and the vestibular system was observed. LIMITATIONS The number of players who sustained a concussion was not large, but numbers were comparable with other studies in this field. There was missing baseline data for vestibular and cervical proprioception testing for some players. CONCLUSIONS Preliminary findings post-concussion suggest an altered balance strategy and trunk muscle control with splinting/over-holding requiring consideration as part of the development of appropriate physiotherapy management strategies.
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Affiliation(s)
- Julie A Hides
- Centre for Musculoskeletal Research, Mary MacKillop Institute for Health Research, Australian Catholic University, Brisbane, QLD, 4102, Australia.
| | - Melinda M Franettovich Smith
- Centre for Musculoskeletal Research, Mary MacKillop Institute for Health Research, Australian Catholic University, Brisbane, QLD, 4102, Australia
| | - M Dilani Mendis
- Centre for Musculoskeletal Research, Mary MacKillop Institute for Health Research, Australian Catholic University, Brisbane, QLD, 4102, Australia; Physiotherapy Department, Mater Health Services, South Brisbane, 4101, Australia
| | - Nigel A Smith
- Centre for Musculoskeletal Research, Mary MacKillop Institute for Health Research, Australian Catholic University, Brisbane, QLD, 4102, Australia
| | - Andrew J Cooper
- Centre for Musculoskeletal Research, Mary MacKillop Institute for Health Research, Australian Catholic University, Brisbane, QLD, 4102, Australia
| | - Julia Treleaven
- Division of Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, 4072, Australia
| | - Felix Leung
- Centre for Musculoskeletal Research, Mary MacKillop Institute for Health Research, Australian Catholic University, Brisbane, QLD, 4102, Australia
| | - Andrew J Gardner
- Priority Research Centre for Stroke and Brain Injury, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2310, Australia; Hunter New England Local Health District Sports Concussion Program, John Hunter Hospital, New Lambton Heights, NSW, 2305, Australia
| | - Paul McCrory
- The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
| | - Nancy L Low Choy
- School of Physiotherapy, Australian Catholic University, Brisbane, QLD, 4014, Australia
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26
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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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27
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Studerus-Germann AM, Engel DC, Stienen MN, von Ow D, Hildebrandt G, Gautschi OP. Three versus seven days to return-to-work after mild traumatic brain injury: a randomized parallel-group trial with neuropsychological assessment. Int J Neurosci 2017; 127:900-908. [PMID: 28042930 DOI: 10.1080/00207454.2017.1278589] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Although most patients with a mild traumatic brain injury (mTBI) recover within days to weeks, some experience persistent physical, cognitive and emotional symptoms, often described as post-concussion syndrome (PCS). The optimal recovery time including return-to-work (RTW) after mTBI is unclear. In this single-centre parallel-group trial, patients assigned three days (3D-group) or seven days (7D-group) sick leave were compared with a comprehensive neuropsychological test battery including the Post-Concussion Symptom Scale (PCSS) within one week, after three and 12 months post-injury. The influence of the effective time until RTW on post-concussional symptoms and cognitive performance was analysed. The 3D-group rated significantly higher mean scores in some PCSS symptoms, tended to fulfil diagnosis criteria of PCS more often and showed better cognitive performance in several neuropsychological test scores than the 7D-group at all three time-points of follow-up. Overall, patients returned to work 11.35 d post-injury, thus distinctly above both recommended sick leaves. There was a trend for longer sick leave in patients randomized into the 3D-group. Further analyses revealed that the group with an absolute RTW within one week showed lower symptom severity in fatigue at 3 and 12 months, less PCS and faster performance in fine motor speed at 12 months than the group with an absolute RTW after one week. Our data underline the heterogeneity of mTBI and show that acute and sub-acute symptoms are not prognostic factors for neuropsychological outcome at one year. Later, ability to work seems to be prognostic for long-term occurrence of PCS.
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Affiliation(s)
- Aline M Studerus-Germann
- a Division of Neuropsychology , Department of Neurology , State Hospital St. Gallen , St. Gallen , Switzerland.,b Department of Psychopathology and Clinical Intervention , University of Zurich , Zurich , Switzerland
| | - Doortje C Engel
- c Department of Neurosurgery , Cantonal Hospital St. Gallen , St. Gallen , Switzerland.,d Department of Neurosurgery , University Hospital Tübingen , Tübingen , Germany
| | - Martin N Stienen
- c Department of Neurosurgery , Cantonal Hospital St. Gallen , St. Gallen , Switzerland.,e Department of Neurosurgery and Faculty of Medicine , University Hospital Geneva , Geneva , Switzerland
| | - Dieter von Ow
- f Emergency Department , Cantonal Hospital St. Galllen , St. Gallen , Switzerland
| | - Gerhard Hildebrandt
- c Department of Neurosurgery , Cantonal Hospital St. Gallen , St. Gallen , Switzerland
| | - Oliver P Gautschi
- c Department of Neurosurgery , Cantonal Hospital St. Gallen , St. Gallen , Switzerland.,f Emergency Department , Cantonal Hospital St. Galllen , St. Gallen , Switzerland
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28
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Pabian PS, Oliveira L, Tucker J, Beato M, Gual C. Interprofessional management of concussion in sport. Phys Ther Sport 2017; 23:123-132. [DOI: 10.1016/j.ptsp.2016.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 06/12/2016] [Accepted: 09/07/2016] [Indexed: 12/14/2022]
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29
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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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Eliyahu L, Kirkland S, Campbell S, Rowe BH. The Effectiveness of Early Educational Interventions in the Emergency Department to Reduce Incidence or Severity of Postconcussion Syndrome Following a Concussion: A Systematic Review. Acad Emerg Med 2016; 23:531-42. [PMID: 26825870 DOI: 10.1111/acem.12924] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 12/30/2015] [Accepted: 01/04/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Concussions or mild traumatic brain injury are a major public health concern accounting for 85% of all brain injuries. Postconcussion syndrome (PCS) has been found to affect between 15 and 25% of patients with concussion 1 year after the initial injury. The goal of this review is to assess the effectiveness of early educational information or interventions provided in the emergency department on the onset and/or severity of PCS. METHODS A comprehensive literature search strategy involving seven electronic databases was developed. A grey literature search of Google Scholar, recent conference proceedings in emergency medicine, bibliographies of included studies, and clinical trial registries was also performed. The citation list was reviewed independently by two reviewers; no restrictions on publication status or language of publication were applied. The Cochrane risk-of-bias tool and the Newcastle-Ottawa scale were used to assess quality. RESULTS From 1,325 citations retrieved, four RCTs and one controlled clinical trial met inclusion criteria. Interventions identified in these studies included: educational information sheets, with or without telephone or in-person follow-up, and one study on bed rest. While rarely requested, one study offered referrals and additional treatment, if needed. None of the studies were deemed to be high quality. Heterogeneity among outcome reporting, follow-up dates and interventions used precluded a pooled analysis. Overall, only two of the five included studies involving adult patients receiving early educational interventions reported a significant improvement in PCS symptoms. No reduction in PCS symptoms was found in the study on bed rest interventions. CONCLUSION Limited evidence exists regarding the effectiveness of early educational interventions following concussion. Standardization of the interventions, outcome measures, and follow-up periods would make quantitative comparisons more valid. Moreover, higher-quality research in the field of early interventions for patients in the acute care setting is urgently required.
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Affiliation(s)
- Leeor Eliyahu
- Department of Emergency Medicine; University of Alberta; Edmonton Alberta Canada
- School of Public Health; University of Alberta; Edmonton Alberta Canada
| | - Scott Kirkland
- Department of Emergency Medicine; University of Alberta; Edmonton Alberta Canada
| | - Sandy Campbell
- J. W. Scott Health Sciences Library; University of Alberta; Edmonton Alberta Canada
| | - Brian H. Rowe
- Department of Emergency Medicine; University of Alberta; Edmonton Alberta Canada
- School of Public Health; University of Alberta; Edmonton Alberta Canada
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Zakzanis KK, Grimes KM, Uzzaman S, Schmuckler MA. Prospection and its relationship to instrumental activities of daily living in patients with mild traumatic brain injury with cognitive impairment. Brain Inj 2016; 30:986-92. [DOI: 10.3109/02699052.2016.1147077] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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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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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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Meehan WP, Mannix R, Monuteaux MC, Stein CJ, Bachur RG. Early symptom burden predicts recovery after sport-related concussion. Neurology 2014; 83:2204-10. [PMID: 25381296 DOI: 10.1212/wnl.0000000000001073] [Citation(s) in RCA: 162] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To identify independent predictors of and use recursive partitioning to develop a multivariate regression tree predicting symptom duration greater than 28 days after a sport-related concussion. METHODS We conducted a prospective cohort study of patients in a sports concussion clinic. Participants completed questionnaires that included the Post-Concussion Symptom Scale (PCSS). Participants were asked to record the date on which they last experienced symptoms. Potential predictor variables included age, sex, score on symptom inventories, history of prior concussions, performance on computerized neurocognitive assessments, loss of consciousness and amnesia at the time of injury, history of prior medical treatment for headaches, history of migraines, and family history of concussion. We used recursive partitioning analysis to develop a multivariate prediction model for identifying athletes at risk for a prolonged recovery from concussion. RESULTS A total of 531 patients ranged in age from 7 to 26 years (mean 14.6 ± 2.9 years). The mean PCSS score at the initial visit was 26 ± 26; mean time to presentation was 12 ± 5 days. Only total score on symptom inventory was independently associated with symptoms lasting longer than 28 days (adjusted odds ratio 1.044; 95% confidence interval [CI] 1.034, 1.054 for PCSS). No other potential predictor variables were independently associated with symptom duration or useful in developing the optimal regression decision tree. Most participants (86%; 95% CI 80%, 90%) with an initial PCSS score of <13 had resolution of their symptoms within 28 days of injury. CONCLUSIONS The only independent predictor of prolonged symptoms after sport-related concussion is overall symptom burden.
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Affiliation(s)
- William P Meehan
- From The Micheli Center for Sports Injury Prevention (W.P.M.), Waltham; and the Sports Concussion Clinic, Division of Sports Medicine (W.P.M., C.J.S.), Division of Emergency Medicine (W.P.M., R.M., M.C.M., R.G.B.), and Brain Injury Center (W.P.M., R.M.), Boston Children's Hospital, MA.
| | - Rebekah Mannix
- From The Micheli Center for Sports Injury Prevention (W.P.M.), Waltham; and the Sports Concussion Clinic, Division of Sports Medicine (W.P.M., C.J.S.), Division of Emergency Medicine (W.P.M., R.M., M.C.M., R.G.B.), and Brain Injury Center (W.P.M., R.M.), Boston Children's Hospital, MA
| | - Michael C Monuteaux
- From The Micheli Center for Sports Injury Prevention (W.P.M.), Waltham; and the Sports Concussion Clinic, Division of Sports Medicine (W.P.M., C.J.S.), Division of Emergency Medicine (W.P.M., R.M., M.C.M., R.G.B.), and Brain Injury Center (W.P.M., R.M.), Boston Children's Hospital, MA
| | - Cynthia J Stein
- From The Micheli Center for Sports Injury Prevention (W.P.M.), Waltham; and the Sports Concussion Clinic, Division of Sports Medicine (W.P.M., C.J.S.), Division of Emergency Medicine (W.P.M., R.M., M.C.M., R.G.B.), and Brain Injury Center (W.P.M., R.M.), Boston Children's Hospital, MA
| | - Richard G Bachur
- From The Micheli Center for Sports Injury Prevention (W.P.M.), Waltham; and the Sports Concussion Clinic, Division of Sports Medicine (W.P.M., C.J.S.), Division of Emergency Medicine (W.P.M., R.M., M.C.M., R.G.B.), and Brain Injury Center (W.P.M., R.M.), Boston Children's Hospital, MA
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Ganti L, Khalid H, Patel PS, Daneshvar Y, Bodhit AN, Peters KR. Who gets post-concussion syndrome? An emergency department-based prospective analysis. Int J Emerg Med 2014; 7:31. [PMID: 25635191 PMCID: PMC4306054 DOI: 10.1186/s12245-014-0031-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2014] [Accepted: 07/28/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The objective of this study was to determine who gets post-concussion syndrome (PCS) after mild traumatic brain injury or head injury. METHODS Patients presented within an hour of mild traumatic brain injury (mTBI). Written informed consent was obtained from all patients, who then provided detailed answers to surveys at the time of injury as well as at 1 week and 1 month follow-up. Statistical analyses were performed using JMP 11.0 for the Macintosh. RESULTS The most commonly reported symptoms of PCS at first follow-up were headache (27%), trouble falling asleep (18%), fatigue (17%), difficulty remembering (16%), and dizziness (16%). Furthermore, only 61% of the cohort was driving at 1 week follow-up, compared to 100% prior to the injury. Linear regression analysis revealed the consumption of alcohol prior to head injury, the mechanism of head injury being a result of motor vehicle collision (MVC) or fall, and the presence of a post-injury headache to be significantly associated with developing PCS at 1 week follow-up, while the occurrence of a seizure post-injury or having an alteration in consciousness post-injury was significantly associated with developing PCS at 1 month follow-up. On multivariate regression analysis, the presence of a headache post-injury was the most robust predictor, retaining statistical significance even after controlling for age, gender, and presence of loss of consciousness (LOC), alteration of consciousness (AOC), post-traumatic amnesia (PTA), seizure, or vomiting. CONCLUSIONS The results of this prospective study suggest that headache right after the head injury, an alteration of consciousness after the head injury, and alcohol consumption prior to the head injury are significant predictors of developing PCS, which occurs with equal frequency in men and women. Early identification of those who are at risk of developing PCS would diminish the burden of the injury and could potentially reduce the number of missed work and school days.
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Affiliation(s)
- Latha Ganti
- North Florida South Georgia Veterans Affairs Medical Center, 1601 Archer Road, Gainesville 32610, FL, USA
| | - Hussain Khalid
- The University of Florida College of Medicine, Gainesville 32610, FL, USA
| | | | - Yasamin Daneshvar
- Department of Emergency Medicine, UF Health, Gainesville 32610, FL, USA
| | - Aakash N Bodhit
- Department of Emergency Medicine, UF Health, Gainesville 32610, FL, USA
| | - Keith R Peters
- Department of Radiology, UF Health, Gainesville 32610, FL, USA
- Department of Neurological Surgery, UF Health, Gainesville 32610, FL, USA
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Abstract
OBJECTIVES To examine the incidence, duration, and clinical course of individual post-concussive symptoms in patients presenting to a pediatric emergency department (ED) with a concussion. METHODS We conducted secondary analysis of a prospective cohort study of patients 11 to 22 years old presenting to the ED of a children's hospital with an acute concussion. The main outcome measure was duration of symptoms, assessed by the Rivermead Post-Concussion Symptoms Questionnaire (RPSQ). Patients initially completed a questionnaire describing mechanism of injury, associated symptoms, past medical history, and the RPSQ, then were serially administered the RPSQ for 3 months after the concussion or until all symptoms resolved. RESULTS Headache, fatigue, dizziness, and taking longer to think were the most common symptoms encountered at presentation, whereas sleep disturbance, frustration, forgetfulness, and fatigue were the symptoms most likely to develop during the follow-up period that had not initially been present. Median duration of symptoms was the longest for irritability (16 days), sleep disturbance (16 days), frustration (14 days), and poor concentration (14 days), whereas nausea, depression, dizziness, and double-vision abated most quickly. One month after injury, nearly a quarter of children still complained of headache, >20% suffered from fatigue, and nearly 20% reported taking longer to think. CONCLUSIONS Among patients presenting to a pediatric ED after a concussion, physical symptoms such as headache predominate immediately after the injury, emotional symptoms tend to develop later in the recovery period, and cognitive symptoms may be present throughout.
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Affiliation(s)
- Matthew A Eisenberg
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - William P Meehan
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rebekah Mannix
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Kraus JF, Hsu P, Schafer K, Afifi AA. Sustained outcomes following mild traumatic brain injury: results of a five-emergency department longitudinal study. Brain Inj 2014; 28:1248-56. [PMID: 24841806 DOI: 10.3109/02699052.2014.916420] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To report on the occurrence of sustained outcomes including post-concussion symptoms, health services used and indicators of social disruption following a mild traumatic brain injury (MTBI). RESEARCH DESIGN A dual cohort comparing MTBI Emergency Department (ED) patients and a comparison group of non-head injured ED patients. METHODS AND PROCEDURES The outcomes measures employed were the Rivermead Post-Concussion Symptoms Questionnaire (RPQ) and indicators of health services used and social disruption all recorded at the ED and at 3 and 6 months post-ED discharge. 'Sustained' meant a positive response to these measures at 3 and 6 months. MAIN OUTCOMES AND RESULTS Reasonable follow-up success was achieved at 3 and 6 months and the cohorts were alike on all demographic descriptors. RPQ average score and symptom occurrence were far more frequent among MTBI patients than for the comparison cohort from 3 to 6 months. The use of health services and indicators of social disruption were also more frequent among MTBI post-discharge patients. CONCLUSIONS These findings argue that some with an MTBI suffer real complaints and they are sustained from 3 to at least 6 months. More effort should be given toward specificity of these symptoms from those reported by members of the comparison group.
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Affiliation(s)
- Jess F Kraus
- Department of Epidemiology, UCLA , San Marcos, CA , USA
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Time course of clinical and electrophysiological recovery after sport-related concussion. J Head Trauma Rehabil 2014; 28:266-73. [PMID: 22588360 DOI: 10.1097/htr.0b013e318247b54e] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND AND PURPOSE Recent neuroimaging studies suggest that abnormalities in brain function after concussion exist beyond the point of observed clinical recovery. This study investigated the relationship between an index of brain dysfunction (traumatic brain injury [TBI] Index), concussion severity, and outcome. METHODS EEG was collected from forehead locations in 65 male athletes with concussion within 24 hours of concussion, with follow-up at 8 and 45 days postinjury. Neurocognitive and symptom assessments were also performed and used to classify subjects in mild or moderate concussion categories. Time to return to play was recorded. RESULTS The TBI Index was higher in the moderate than mild concussion group at injury, day 8, and day 45. The moderate group had increased symptoms and decreased cognitive performance only at the time of injury. At the time of injury, only the TBI Index was significantly associated with the length of time to return to play. CONCLUSIONS Recovery of brain function after sport-related concussion may extend well beyond the time course of clinical recovery and be related to clinical severity. An index of brain dysfunction may be an objective indicator of injury, recovery, and readiness to return to play. The relatively small sample indicates the need for further study on the time course of physiological recovery.
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40
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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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Abstract
Context: Currently, no consensus exists for grading the severity of concussions. Identification of risk factors that may affect concussion risk and the likelihood of prolonged recovery can be of value to providers who manage concussion. Evidence Acquisition: Relevant studies were identified through MEDLINE (1996-2011) using the keywords concussion, postconcussive syndrome, and risk or risk factor. Targeted searches for specific risk factors were conducted with additional keywords, such as gender and migraine. Manual review of reference lists was also performed to identify pertinent literature. Results: For risk factors of concussion, history of prior concussion and female sex have the most supporting evidence. Sports with consistently high risk for sustaining a concussion include football, men’s ice hockey, and women’s soccer. Younger athletes appear to be more susceptible to concussion, but data are limited and inconsistent. Protective equipment does not definitively alter concussion risk, though it protects against other injuries. Symptoms such as long headaches, migraines, amnesia, and multiple symptoms appear to be associated with prolonged recovery. Younger age may also increase the risk of prolonged concussion. Conclusion: High-quality evidence for risk modifiers in concussion remains sparse. Prior concussion, collision sports, female sex, and women’s soccer are the strongest known risk factors. Evidence for most other factors is inconclusive.
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Matuseviciene G, Borg J, Stålnacke BM, Ulfarsson T, de Boussard C. Early intervention for patients at risk for persisting disability after mild traumatic brain injury: a randomized, controlled study. Brain Inj 2013; 27:318-24. [PMID: 23438351 DOI: 10.3109/02699052.2012.750740] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVE To investigate the effect of an early intervention visit in addition to written information and treatment as usual for patients with an estimated high risk for persisting disability after a mild traumatic brain injury (MTBI). RESEARCH DESIGN Randomized controlled trial. METHODS One hundred and seventy-three patients, aged 15-70 years with a Glasgow coma scale of 14-15 were included. All received written information about MTBI. Ninety-seven patients who reported three or more symptoms according to the rivermead post-concussion symptoms questionnaire (RPQ) at 10 days after the injury were considered as high-risk patients and were randomized to either early visit to a doctor or to treatment as usual (TAU); all patients including the 76 low-risk patients were followed-up at 3 months. Completion rate was 83%. Outcome measures included RPQ and the hospital anxiety and depression scale. RESULTS RPQ symptoms decreased significantly in both randomized groups, but were not significantly different in the groups at 3 months. At 3 months, anxiety and depression scores did not differ between groups. CONCLUSIONS An early intervention, offered to patients with an estimated high risk for persisting disability, had no additional effect on symptom level at 3 months after MTBI as compared to TAU.
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Affiliation(s)
- Giedre Matuseviciene
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden.
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Evaluation and management of mild traumatic brain injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2013; 73:S307-14. [PMID: 23114486 DOI: 10.1097/ta.0b013e3182701885] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND An estimated 1.1 million people sustain a mild traumatic brain injury (MTBI) annually in the United States. The natural history of MTBI remains poorly characterized, and its optimal clinical management is unclear. The Eastern Association for the Surgery of Trauma had previously published a set of practice management guidelines for MTBI in 2001. The purpose of this review was to update these guidelines to reflect the literature published since that time. METHODS The PubMed and Cochrane Library databases were searched for articles related to MTBI published between 1998 and 2011. Selected older references were also examined. RESULTS A total of 112 articles were reviewed and used to construct a series of recommendations. CONCLUSION The previous recommendation that brain computed tomographic (CT) should be performed on patients that present acutely with suspected brain trauma remains unchanged. A number of additional recommendations were added. Standardized criteria that may be used to determine which patients receive a brain CT in resource-limited environments are described. Patients with an MTBI and negative brain CT result may be discharged from the emergency department if they have no other injuries or issues requiring admission. Patients taking warfarin who present with an MTBI should have their international normalized ratio (INR) level determined, and those with supratherapeutic INR values should be admitted for observation. Deficits in cognition and memory usually resolve within 1 month but may persist for longer periods in 20% to 40% of cases. Routine use of magnetic resonance imaging, positron emission tomography, nuclear magnetic resonance, or biochemical markers for the clinical management of MTBI is not supported at the present time.
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Lannsjö M, Backheden M, Johansson U, Af Geijerstam JL, Borg J. Does head CT scan pathology predict outcome after mild traumatic brain injury? Eur J Neurol 2012; 20:124-9. [PMID: 22812542 DOI: 10.1111/j.1468-1331.2012.03813.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Accepted: 06/12/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE More evidence is needed to forward our understanding of the key determinants of poor outcome after mild traumatic brain injury (MTBI). A large, prospective, national cohort of patients was studied to analyse the effect of head CT scan pathology on the outcome. METHODS One-thousand two-hundred and sixty-two patients with MTBI (Glasgow Coma Scale score 15) at 39 emergency departments completed a study protocol including acute head CT scan examination and follow-up by the Rivermead Post Concussion Symptoms Questionnaire and the Glasgow Outcome Scale Extended (GOSE) at 3 months after MTBI. Binary logistic regression was used for the assessment of prediction ability. RESULTS In 751 men (60%) and 511 women (40%), with a mean age of 30 years (median 21, range 6-94), we observed relevant or suspect relevant pathologic findings on acute CT scan in 52 patients (4%). Patients aged below 30 years reported better outcome both with respect to symptoms and GOSE as compared to patients in older age groups. Men reported better outcome than women as regards symptoms (OR 0.64, CI 0.49-0.85 for ≥3 symptoms) and global function (OR 0.60, CI 0.39-0.92 for GOSE 1-6). CONCLUSIONS Pathology on acute CT scan examination had no effect on self-reported symptoms or global function at 3 months after MTBI. Female gender and older age predicted a less favourable outcome. The findings support the view that other factors than brain injury deserve attention to minimize long-term complaints after MTBI.
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Affiliation(s)
- M Lannsjö
- Department of Rehabilitation Medicine, Institute of Neuroscience, University of Uppsala, Uppsala, Sweden.
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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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