Sustained outcomes following mild traumatic brain injury: results of a five-emergency department longitudinal study

Role of sex and gender in concussion outcome differences among patients presenting to the emergency department: a systematic review

OBJECTIVE

This systematic review aimed to identify research involving adults presenting to the emergency department (ED) with a concussion to document the reporting of sex and/or gender according to the Canadian Institutes of Health Research (CIHR) guidelines, the prevalence of sex and gender-based analysis (SGBA) and to summarise sex and/or gender-based differences in ED presentation, management and outcomes.

DESIGN

Systematic review.

METHODS

Electronic databases and grey literature were searched to identify studies that recruited adult patients with concussion from the ED. Two independent reviewers identified eligible studies, assessed quality and extracted data. A descriptive summary of the evidence was generated, and sex and/or gender reporting was examined for accuracy according to standardised criteria.

RESULTS

Overall, 126 studies were included in the analyses. A total of 80 (64%) studies reported sex and/or gender as demographic information, of which 51 (64%) included sex and/or gender in their analysis; however, 2 (3%) studies focused on an SGBA. Sex was more accurately reported in alignment with CIHR definitions than gender (94% vs 12%; p<0.0001). In total, 25 studies used an SGBA for outcomes of interest. Males and females experience different causes of concussion, 60% of studies documented that females had less frequent CT scanning while in the ED, and 57% of studies reported that postconcussion syndrome was more prevalent in females and women.

CONCLUSION

This systematic review highlighted that sex is reported more accurately than gender, approximately half of studies did not report either sex and/or gender as demographic information, and one-third of studies did not include SGBA. There were important sex and gender differences in the cause, ED presentation, management and outcomes of concussions.

PROSPERO REGISTRATION NUMBER

CRD42021258613.

Salivary Cortisol Dynamics After Mild Traumatic Brain Injury

OBJECTIVE

To assess mild traumatic brain injury (mTBI)-related alterations in baseline (resting) salivary cortisol and cortisol reactivity to cognitive and exercise stressors, which are frequently encountered during mTBI rehabilitation and recovery.

SETTING

Persons with mTBI were recruited from a level 1 trauma center emergency department. Uninjured controls (UCs) were recruited from the community.

PARTICIPANTS

Participants were 37 individuals with mTBI and 24 UCs. All patients with mTBI were enrolled at 7 ± 3 days post-injury, met the American Congress of Rehabilitation Medicine definition of mTBI, and had no acute intracranial findings on clinical neuroimaging (if performed).

DESIGN

A prospective cohort study design was used. All participants provided saliva samples 10 times during each of 2 visits spaced 3 weeks apart (1 week and 1 month post-injury for the mTBI group). Each visit included baseline saliva sampling and sampling to evaluate reactivity to a cognitive stressor (Paced Auditory Serial Addition Test) and physical stressor (Buffalo Concussion Treadmill Test [BCTT]).

MAIN OUTCOME MEASURE

Natural log-transformed salivary cortisol was measured by enzyme immunoassay. Cortisol was predicted using a linear mixed-effects model by group (mTBI and UC), visit (1 week and 1 month), and saliva sample.

RESULTS

Mean salivary cortisol was higher in the mTBI group (1.67 nmol/L [95% CI 1.42-1.72]) than in controls (1.30 nmol/L [1.12-1.47]), without an mTBI × time interaction. At 1 week, the mTBI group had greater cortisol reactivity in response to the BCTT.

CONCLUSIONS

Higher cortisol in individuals with mTBI at 1 week and 1 month post-injury extends previous findings into the subacute recovery period. Furthermore, the mTBI group demonstrated a greater cortisol response to mild-to-moderate aerobic exercise (BCTT) at 1 week post-injury. Given the increasing role of exercise in mTBI rehabilitation, further research is warranted to replicate these findings and identify the clinical implications, if any, of enhanced hypothalamic-pituitary-adrenal axis responses to exercise in civilians with recent mTBI.

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

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

Diffusion-Weighted Imaging in Mild Traumatic Brain Injury: A Systematic Review of the Literature

There is evidence that diffusion-weighted imaging (DWI) is able to detect tissue alterations following mild traumatic brain injury (mTBI) that may not be observed on conventional neuroimaging; however, findings are often inconsistent between studies. This systematic review assesses patterns of differences in DWI metrics between those with and without a history of mTBI. A PubMed literature search was performed using relevant indexing terms for articles published prior to May 14, 2020. Findings were limited to human studies using DWI in mTBI. Articles were excluded if they were not full-length, did not contain original data, if they were case studies, pertained to military populations, had inadequate injury severity classification, or did not report post-injury interval. Findings were reported independently for four subgroups: acute/subacute pediatric mTBI, acute/subacute adult mTBI, chronic adult mTBI, and sport-related concussion, and all DWI acquisition and analysis methods used were included. Patterns of findings between studies were reported, along with strengths and weaknesses of the current state of the literature. Although heterogeneity of sample characteristics and study methods limited the consistency of findings, alterations in DWI metrics were most commonly reported in the corpus callosum, corona radiata, internal capsule, and long association pathways. Many acute/subacute pediatric studies reported higher FA and lower ADC or MD in various regions. In contrast, acute/subacute adult studies most commonly indicate lower FA within the context of higher MD and RD. In the chronic phase of recovery, FA may remain low, possibly indicating overall demyelination or Wallerian degeneration over time. Longitudinal studies, though limited, generally indicate at least a partial normalization of DWI metrics over time, which is often associated with functional improvement. We conclude that DWI is able to detect structural mTBI-related abnormalities that may persist over time, although future DWI research will benefit from larger samples, improved data analysis methods, standardized reporting, and increasing transparency.

Predictive factors for community integration among Nepalese persons after traumatic brain injury

Background

Various factors affect the community integration (CI) of persons experiencing traumatic brain injury (TBI). To ensure positive outcomes in terms of life at home, social activities, and productive work among persons suffering TBI, it is necessary to understand the factors that facilitate or impede CI.

Purpose

To compare CI by looking at demographic and clinical characteristics and determine significant predictors of CI among TBI Nepalese persons.

Methods

120 participants were selected using a stratified random sampling technique. A questionnaire was used to identify the participants’ demographic and clinical characteristics, and the Community Integration Questionnaire was used to measure CI. Univariate and multivariate analyses were performed for demographic and clinical factors associated with community integration.

Results

Using univariate analysis, male, employed, living with family, and independence in performing activities of daily living had significantly higher CI scores than female (t = −4.18, p<.000), unemployed (t = −10.52, p<.000), living with friends (t = −3.30, p<.001), and those with moderate to slight dependence (t = −2.83, p<.005). The multivariate analysis revealed that employment status, living with family, and length of hospital stay were significant predictors of CI among TBI Nepalese persons.

Conclusion

Employment status, living with family, and length of hospital stay were significant predictors of CI. These findings suggest that rehabilitation efforts should focus on minimizing hospital stay and promoting both productive and social activities among people surviving TBI.

Symptom Frequency and Persistence in the First Year after Traumatic Brain Injury: A TRACK-TBI Study

Symptom endorsement after traumatic brain injury (TBI) is common acutely post-injury and is associated with other adverse outcomes. Prevalence of persistent symptoms has been debated, especially in mild TBI (mTBI). A cohort of participants ≥17 years with TBI (n = 2039), 257 orthopedic trauma controls (OTCs), and 300 friend controls (FCs) were enrolled in the TRACK-TBI study and evaluated at 2 weeks and 3, 6, and 12 months post-injury using the Rivermead Post-Concussion Symptoms Questionnaire (RPQ). TBI participants had significantly higher symptom burden than OTCs or FCs at all times, with average scores more than double. TBI cases showed significant decreases in RPQ score between each evaluation (p < 0.001), decreasing ∼1.7 points per month between 2 weeks and 3 months and 0.2 points per month after that. More than 50% of the TBI sample, including >50% of each of the mild and moderate/severe TBI subsamples, continued to endorse three or more symptoms as worse than pre-injury through 12 months post-injury. A majority of TBI participants who endorsed a symptom at 3 months or later did so at the next evaluation as well. Contrary to reviews that report symptom resolution by 3 months post-injury among those with mTBI, this study of participants treated at level 1 trauma centers and having a computed tomography ordered found that persistent symptoms are common to at least a year after TBI. Additionally, although symptom endorsement was not specific to TBI given that they were also reported by OTC and FC participants, TBI participants endorsed over twice the symptom burden compared with the other groups.

Trajectories of Persistent Postconcussion Symptoms and Factors Associated with Symptom Reporting after Mild Traumatic Brain Injury

OBJECTIVE

To examine the trajectories of persistent postconcussion symptoms (PPCS) after mild traumatic brain injury (MTBI) and to investigate which injury-related and personal factors are associated with symptom reporting.

DESIGN

Prospective longitudinal cohort study. Follow-up at 3 and 12 months postinjury.

SETTING

A level 1 trauma center and an emergency outpatient clinic.

PARTICIPANTS

Patients with MTBI (n=358), trauma controls (n=75), and community controls (n=78).

MAIN OUTCOME MEASURES

Symptoms were assessed with the British Columbia Postconcussion Symptom Inventory. Participants were categorized as having moderate to severe PPCS (msPPCS) when reporting ≥3 moderate/severe symptoms or a BC-PSI total score of ≥13. BC-PSI total scores were compared between the groups and were further used to create cut-offs for reliable change by identifying uncommon and very uncommon change in symptoms in the community control group. Associations between symptom reporting and 25 injury-related and personal factors were examined.

RESULTS

The MTBI group had a similar prevalence of msPPCS at 3 and 12 months (21%), and reported more symptoms than the control groups. Analyses of individual trajectories, however, revealed considerable change in both msPPCS and BC-PSI total scores in the MTBI group, where both worsening and improvement was common. Intracranial lesions on CT were associated with a greater likelihood of improving from 3 to 12 months. Those with msPPCS at both assessments were more likely to be women and to have these personal preinjury factors: reduced employment, pain, poor sleep, low resilience, high neuroticism and pessimism, and a psychiatric history.

CONCLUSIONS

Group analyses suggest a stable prevalence of msPPCS the first year postinjury. However, there was considerable intra-individual change. Several personal factors were associated with maintaining symptoms throughout the first year.

Photophobia Associated with Traumatic Brain Injury: A Systematic Review and Meta-analysis

SIGNIFICANCE

This study reports the prevalence and relative risk of photophobia in patients with traumatic brain injury (TBI).

OBJECTIVES

This study aimed to conduct a systematic review and meta-analysis to determine the prevalence and relative risk of photophobia in patients with TBI.

DATA SOURCES

Three databases were used for literature search: PubMed, EMBASE, and Cochrane Library.

STUDY APPRAISAL AND SYNTHESIS METHODS

Publications reporting the prevalence of photophobia after TBI in patients of any age were included. A series of meta-regression analyses based on a generalized linear mixed model was performed to identify potential sources of heterogeneity in the prevalence estimates.

RESULTS

Seventy-five eligible publications were identified. The prevalence of photophobia was 30.46% (95% confidence interval [CI], 20.05 to 40.88%) at 1 week after the injury. Prevalence decreased to 19.34% (95% CI, 10.40 to 28.27%) between 1 week and 1 month after TBI and to 13.51% (95% CI, 5.77 to 21.24%) between 1 and 3 months after the injury. The rapid decrease in the prevalence of photophobia in the first 3 months after a TBI injury was significant (P < .001). Three months post-TBI, the prevalence of photophobia leveled off to a near plateau with nonsignificant variability, increasing between 3 and 6 months (17.68%; 95% CI, 9.05 to 26.32%) and decreasing between 6 and 12 months since TBI (14.85%; 95% CI, 6.80 to 22.90%). Subgroup analysis of 14 publications that contained control data showed that the estimated risk ratio for photophobia was significantly higher in the TBI than in the control group during the entire 12 months after TBI.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

This study demonstrates that photophobia is a frequent complaint after TBI, which largely resolves for many individuals within 3 months after the injury. For some patients, however, photophobia can last up to 12 months and possibly longer. Developing an objective quantitative methodology for measuring photophobia, validating a dedicated photophobia questionnaire, and having a specific photophobia International Classification of Diseases, Tenth Revision code would greatly improve data gathering and analysis.

User experience (re)design and evaluation of a self-guided, mobile health app for adolescents with mild Traumatic Brain Injury

Mild Traumatic Brain Injury (mTBI) is a significant cause of morbidity for adolescents. Currently, there is a lack of evidence-based interventions to address common sequelae of mTBI. To address this gap, we designed a program to promote recovery for adolescents following mTBI. Preliminary testing of the Self-Monitoring Activity Regulation and Relaxation Treatment (SMART) program demonstrated good usability but indicated a need for modifications to the program. The SMART application was redesigned with the addition of more interactive and gamified components. Content was also reframed to specifically target and engage adolescents with mTBI. We describe the usability evaluation of the updated SMART application. Children aged 11-18 years diagnosed with mTBI who were 1 to 6 months post mTBI were recruited to participate in a 1-2-hour usability session in which they thought aloud and responded to targeted usability-related questions during their interaction with the SMART program. After completing the session, participants rated their usability experience using the System Usability Scale (SUS) and rated the overall user-friendliness of the program. Participants' responses during the session were qualitatively coded and analyzed. Six adolescents participated in a usability session (average age = 13.7 years). On the SUS, participants rated the program as highly usable (M = 85.6, SD = 3.24). They also had overwhelmingly positive feedback regarding the content, design and structure of the program. Overall, findings suggest that the redesigned SMART program was usable, acceptable, and relevant to adolescents with mTBI. Based on adolescents' feedback, additional modifications were made before the program undergoes efficacy testing.

Persistent Postconcussion Symptoms: An Expert Consensus-Based Definition Using the Delphi Method

OBJECTIVE

To provide an expert consensus definition of persistent postconcussion symptoms following a mild traumatic brain injury (mTBI).

PARTICIPANTS

Canadian healthcare professionals caring for patients with mTBI.

DESIGN

Online Delphi process.

MAIN MEASURES

A first Delphi round documented important dimensions or criteria to consider when defining persistent symptoms. Expert opinions were then resubmitted in 4 subsequent Delphi rounds and their relevance was rated using a 9-point Likert scale. An item with a median rating of 7 or more and a sufficient level of agreement were considered consensual.

RESULTS

After 5 rounds, consensus was reached on a set of criteria that can be summarized as follows: presence of any symptom that cannot be attributed to a preexisting condition and that appeared within hours of an mTBI, that is still present every day 3 months after the trauma, and that has an impact on at least one sphere of a person's life.

CONCLUSION

This Delphi consensus proposes a set of criteria that support a more uniform definition of persistent symptoms in mild TBI among clinicians and researchers. This definition may help clinicians better identify persistent postconcussion symptoms and improve patient management.

Clinical Predictors of 3- and 6-Month Outcome for Mild Traumatic Brain Injury Patients with a Negative Head CT Scan in the Emergency Department: A TRACK-TBI Pilot Study

A considerable subset of mild traumatic brain injury (mTBI) patients fail to return to baseline functional status at or beyond 3 months postinjury. Identifying at-risk patients for poor outcome in the emergency department (ED) may improve surveillance strategies and referral to care. Subjects with mTBI (Glasgow Coma Scale 13–15) and negative ED initial head CT < 24 h of injury, completing 3- or 6-month functional outcome (Glasgow Outcome Scale-Extended; GOSE), were extracted from the prospective, multicenter Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) Pilot study. Outcomes were dichotomized to full recovery (GOSE = 8) vs. functional deficits (GOSE < 8). Univariate predictors with p < 0.10 were considered for multivariable regression. Adjusted odds ratios (AOR) were reported for outcome predictors. Significance was assessed at p < 0.05. Subjects who completed GOSE at 3- and 6-month were 211 (GOSE < 8: 60%) and 185 (GOSE < 8: 65%). Risk factors for 6-month GOSE < 8 included less education (AOR = 0.85 per-year increase, 95% CI: (0.74–0.98)), prior psychiatric history (AOR = 3.75 (1.73–8.12)), Asian/minority race (American Indian/Alaskan/Hawaiian/Pacific Islander) (AOR = 23.99 (2.93–196.84)), and Hispanic ethnicity (AOR = 3.48 (1.29–9.37)). Risk factors for 3-month GOSE < 8 were similar with the addition of injury by assault predicting poorer outcome (AOR = 3.53 (1.17–10.63)). In mTBI patients seen in urban trauma center EDs with negative CT, education, injury by assault, Asian/minority race, and prior psychiatric history emerged as risk factors for prolonged disability.

Predictors for Psychological Distress 2 Months After Mild Traumatic Brain Injury

Objective: To predict psychological distress at 2 months for patients with mild traumatic brain injury.

Method: A prospective cohort study of 162 patients with mild traumatic brain injury (MTBI) admitted consecutively to an outpatient clinic at Haukeland University Hospital, Norway. Demographic data were obtained from Statistics Norway and injury characteristics were obtained from the hospital records. Sick leave data from the last year before the injury were obtained from The Norwegian Labor and Welfare Service. Self-report questionnaires were used to obtain history about earlier disease and symptom profiles. The Hospital Anxiety and Depression Scale (HAD) detecting states of depression and anxiety were used as the dependent variable in a stepwise linear regression. Pre-injury factors and injury-related factors were examined as potential predictors for HAD.

Results: In the first steps we observed a significant association between HAD at 2 months and education, whiplash associated disorder (WAD), and earlier sick listed with a psychiatric diagnosis. In the final step there was an association only between HAD and self-reported anxiety and WAD. There were no associations between HAD and injury-characteristics like severity at Glasgow Coma Scale or intracranial injury.

Conclusion: Patients with low education, earlier psychiatric diagnosis, self-reported earlier anxiety and WAD were more likely to develop a psychological distress after a MTBI. These findings should be taken into consideration when treating patients with MTBI.

Concussion reporting, knowledge and attitudes in Irish amateur gaelic games athletes

OBJECTIVES

To examine self-reported concussion history, knowledge and attitudes towards concussion reporting and education in Irish adult Gaelic games players.

DESIGN

Cross-sectional survey.

SETTING

Data were collected using an online survey instrument.

PARTICIPANTS

Two hundred and sixteen adult Gaelic games athletes (106 male, 110 female).

MAIN OUTCOME MEASURES

Self-reported concussion history for the previous season, reporting history for participants' most recent concussion, concussion knowledge, willingness to report future concussions in a variety of situations and desire for further concussion education.

RESULTS

Seventy-three percent of participants suspected they had sustained a concussion in the past. Most (72.2%) informed someone of their most recent concussion, although two-thirds continued to play during their most recent concussion. Participants had a good overall understanding of concussion, although concussion knowledge score was not associated with safer behaviour following participants' most recent concussion. While most agreed that concussion is a serious injury (95.8%), 46.8% would not report a concussion during important games.

CONCLUSIONS

The high proportion of participants playing following concussion and their reluctance to report concussions during important games is concerning. Interventions aimed at improving attitudes towards concussion reporting among athletes and other stakeholders are required to improve concussion management in amateur Gaelic games athletes.

Molecular imaging of neuroinflammation in patients after mild traumatic brain injury: a longitudinal 123 I-CLINDE single photon emission computed tomography study

BACKGROUND AND PURPOSE

Neuroinflammation has been proposed as part of the pathogenesis of post-concussion symptoms (PCS), but the inflammatory response of the human brain to mild traumatic brain injury (mTBI) remains unknown. We hypothesized that a neuroinflammatory response is present in mTBI at 1-2 weeks post-injury and persists in patients with PCS.

METHODS

We scanned 14 patients with mTBI without signs of structural damage at 1-2 weeks and 3-4 months post-injury and 22 healthy controls once using the single photon emission computed tomography tracer ¹²³ I-CLINDE, which visualizes translocator protein (TSPO), a protein upregulated in active immune cells. PCS was defined as three or more persisting symptoms from the Rivermead Post Concussion Symptoms Questionnaire at 3 months post-injury.

RESULTS

Across brain regions, patients had significantly higher ¹²³ I-CLINDE binding to TSPO than healthy controls, both at 1-2 weeks after the injury in all patients (P = 0.011) and at 3-4 months in the seven patients with PCS (P = 0.006) and in the six patients with good recovery (P = 0.018). When the nine brain regions were tested separately and results were corrected for multiple comparisons, no individual region differed significantly, but all estimated parameters indicated increased ¹²³ I-CLINDE binding to TSPO, ranging from 2% to 19% in all patients at 1-2 weeks, 13% to 27% in patients with PCS at 3-4 months and -9% to 17% in patients with good recovery at 3-4 months.

CONCLUSIONS

Neuroinflammation was present in mTBI at 1-2 weeks post-injury and persisted at 3-4 months post-injury with a tendency to be most pronounced in patients with PCS.

Mental Fatigue and Functional Near-Infrared Spectroscopy (fNIRS) - Based Assessment of Cognitive Performance After Mild Traumatic Brain Injury

Pathological mental fatigue after mild traumatic brain injury (TBI-MF) is characterized by pronounced mental fatigue after cognitive activity. The neurological origin is unknown, and we aimed in the present study to investigate how prolonged mental activity affects cognitive performance and its neural correlates in individuals with TBI-MF. We recruited individuals with TBI-MF (n = 20) at least 5 months after injury, and age-matched healthy controls (n = 20). We used functional near-infrared spectroscopy (fNIRS) to assess hemodynamic changes in the frontal cortex. The self-assessed mental energy level was measured with a visual analog scale (VAS) before and after the experimental procedure. A battery of six neuropsychological tests including Stroop–Simon, Symbol Search, Digit Span, Parallel Serial Mental Operation (PaSMO), Sustained Attention and Working Memory test, and Digit Symbol Coding (DSC) were used. The sequence was repeated once after an 8 min sustained-attention test. The test procedure lasted 2½ h. The experimental procedure resulted in a decrease in mental energy in the TBI-MF group, compared to controls (interaction, p < 0.001, η_p² = 0.331). The TBI-MF group performed at a similar level on both DSC tests, whereas the controls improved their performance in the second session (interaction, p < 0.01, η_p² = 0.268). During the Stroop–Simon test, the fNIRS event-related response showed no time effect. However, the TBI-MF group exhibited lower oxygenated hemoglobin (oxy-Hb) concentrations in the frontal polar area (FPA), ventrolateral motor cortex, and dorsolateral prefrontal cortex (DLPFC) from the beginning of the test session. A Stroop and Group interaction was found in the left ventrolateral prefrontal cortex showing that the TBI-MF group did have the same oxy-Hb concentration for both congruent and incongruent trials, whereas the controls had more oxy-Hb in the incongruent trial compared to the congruent trial (interaction, p < 0.01, η_p² = 0.227). In sum these results indicate that individuals with TBI-MF have a reduced ability to recruit the frontal cortex, which is correlated with self-reported mental fatigue. This may result both in deterioration of cognitive function and the experience of a mental fatigue after extended mental activity.

The Sport Concussion Assessment Tool (SCAT2) for evaluating civilian mild traumatic brain injury. A pilot normative study

Self-report measures, particularly symptom inventories, are critical tools for identifying patients with persistent post-concussion symptoms and their follow-up. Unlike in military or sports-related assessment, in general civilian settings pre-injury levels of concussion-like symptoms are lacking. Normative data are available in adolescent and college populations, but no reference data exist to guide clinical adult explorations. The purpose of this study was to use the second edition of the Sport Concussion Assessment Tool (SCAT2) to profile a cohort of 60 healthy community volunteers who had not sustained a head injury. Participating volunteers underwent MRI scanning and were evaluated with the Hospital Anxiety and Depression Scale (HADS). Participants reported a median of 3 concussion-like symptoms and the 97.5 percentile score was found at 10.5 symptoms, out of a total of 22. The median severity score was 4.9 points, and 28.9 was the upper limit of the reference interval. Only 10 participants (16.7%) did not endorse any symptom. The most frequently endorsed symptom was feeling difficulty in concentrating, with 41.7% of the sample reporting it. Age, sex and general distress, anxiety and depressive symptoms were not associated with concussion-like symptoms. Our data yielded elevated cut-offs scores for both the number of symptoms and the symptom severity. In conclusion, postconcussive-like symptoms are frequent in the general non-concussed adult population and it should be taken into account in any future models developed for screening patients at risk of developing physical, cognitive, and psychological complaints following mild traumatic injury.

Prognostic Value of S-100β Protein for Prediction of Post-Concussion Symptoms after a Mild Traumatic Brain Injury: Systematic Review and Meta-Analysis

This systematic review and meta-analysis aimed to determine the prognostic value of S-100β protein to identify patients with post-concussion symptoms after a mild traumatic brain injury (mTBI). A search strategy was submitted to seven databases from their inception to October 2016. Individual patient data were requested. Cohort studies evaluating the association between S-100β protein level and post-concussion symptoms assessed at least seven days after the mTBI were considered. Outcomes were dichotomized as persistent (≥3 months) or early (≥7 days <3 months). Our search strategy yielded 23,298 citations of which 29 studies including between seven and 223 patients (n = 2505) were included. Post-concussion syndrome (PCS) (16 studies) and neuropsychological symptoms (9 studies) were the most frequently assessed outcomes. The odds of having persistent PCS (odds ratio [OR] 0.62, 95% confidence interval [CI]: 0.34-1.12, p = 0.11, I² 0% [n = five studies]) in patients with an elevated S-100β protein serum level were not significantly different from those of patients with normal values while the odds of having early PCS (OR 1.67, 95% CI: 0.98-2.85, p = 0.06, I² 38% [n = five studies]) were close to statistical significance. Similarly, having an elevated S-100β protein serum level was not associated with the odds of returning to work at six months (OR 2.31, 95% CI: 0.50-10.64, p = 0.28, I² 22% [n = two studies]). Overall risk of bias was considered moderate. Results suggest that the prognostic biomarker S-100β protein has a low clinical value to identify patients at risk of persistent post-concussion symptoms. Variability in injury to S-100ß protein sample time, mTBI populations, and outcomes assessed could potentially explain the lack of association and needs further evaluation.

Concussion and the autonomic nervous system: An introduction to the field and the results of a systematic review

BACKGROUND

Recent evidence suggests that autonomic nervous dysfunction may be one of many potential factors contributing to persisting post-concussion symptoms.

OBJECTIVE

This is the first systematic review to explore the impact of concussion on multiple aspects of autonomic nervous system functioning.

METHODS

The methods employed are in compliance with the American Academy of Neurology (AAN) and PRISMA standards. Embase, MEDLINE, PsychINFO, and Science Citation Index literature searches were performed using relevant indexing terms for articles published prior to the end of December 2016. Data extraction was performed by two independent groups, including study quality indicators to determine potential risk for bias according to the 4-tiered classification scheme of the AAN.

RESULTS

Thirty-six articles qualified for inclusion in the analysis. Only three studies (one Class II and two Class IV) did not identify anomalies in measures of ANS functioning in concussed populations.

CONCLUSIONS

The evidence supports the conclusion that it is likely that concussion causes autonomic nervous system anomalies. An awareness of this relationship increases our understanding of the physical impact of concussion, partially explains the overlap of concussion symptoms with other medical conditions, presents opportunities for further research, and has the potential to powerfully inform treatment decisions.

Use of general practice before and after mild traumatic brain injury: a nationwide population-based cohort study in Denmark

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.

The Structure of the Rivermead Post-Concussion Symptoms Questionnaire in Australian Adults with Traumatic Brain Injury

Background and aims: Many sustaining traumatic brain injury (TBI) suffer ongoing post-concussion symptoms (PCS). The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) is widely used, although there is disagreement about its structure. This study compared the fit of published RPQ structures with a four-factor structure derived from a large adult sample with TBI in Tasmania.

Method: 661 adults with TBI completed the RPQ at approximately one month post injury. Exploratory factor analysis (EFA), using the first half of the sample (n = 330), suggested a four-factor solution. This was compared with models reported in the literature with the second half of the sample (n = 331), using structural equation modelling. Trajectory of recovery across these factors was examined within subsamples at 1, 3, 6 and 12 months following TBI.

Results: Inter-correlations between items were strongest for somatic, cognitive and emotional functioning items and the EFA identified a four-factor model. Fit was examined utilising bootstrapping for model comparison. The data at 1 month following TBI best fitted the four-factor model (CFI = .95, RMSEA = .060 (.049–.071) and factors had adequate internal consistency (r = .61–.89). This model appeared a good fit and clinically useful across time points to 12 months post injury.

Conclusions: Data best fitted a four-factor model, identified using a rigorous statistical approach. Clinicians and clinical researchers may use this preferred model to provide more specific measurement of the severity of PCS. Future research could attempt replication within international samples.

Mild Traumatic Brain Injury: Longitudinal Study of Cognition, Functional Status, and Post-Traumatic Symptoms

More than 75% of traumatic brain injuries (TBIs) seeking medical attention are mild, and outcome in that group is heterogeneous. Until sensitive and valid biomarkers are identified, methods are needed to classify mild TBI into more homogeneous subgroups. Four hundred twenty-one adults with mild TBI were divided into groups based on Glasgow Coma Scale (GCS) 13-15 without computed tomography (CT) abnormalities, GCS 15 with CT abnormalities, and GCS 13-14 with CT abnormalities, and were compared with 120 trauma controls on 1-month and 1-year outcomes. At 1 month post-injury, almost all neuropsychological variables differed significantly among the groups. Compared with trauma controls, the GCS 13-15 CT normal group showed no significant differences on any neuropsychological measure or Glasgow Outcome Scale (GOS). The GCS 15 CT abnormal group performed significantly worse on only a measure of episodic memory and learning (Selective Reminding Recall [SRCL]) and GOS, and the GCS 13-14 CT abnormal group performed significantly worse on most neuropsychological measures and GOS. At 1 year post-injury, except for an isolated difficulty on SRCL in the GCS 13-14 CT abnormal group, no differences were observed on any neuropsychological measures nor on GOS. Mean percent of total post-traumatic symptoms endorsed as new or worse and percent endorsing three or more symptoms differed significantly (p < 0.001), with each TBI subgroup reporting significantly more symptoms than the trauma controls at both 1 month and 1 year. In conclusion, this subgrouping improves granularity within mild TBI. While most neuropsychological and functional differences abate by 1 year, reporting three or more post-traumatic symptoms remain for about half of individuals.

Modeling community integration in workers with delayed recovery from mild traumatic brain injury

Background

Delayed recovery in persons after mild traumatic brain injury (mTBI) is poorly understood. Community integration (CI) is endorsed by persons with neurological disorders as an important outcome. We aimed to describe CI and its associated factors in insured Ontario workers with delayed recovery following mTBI.

Methods

A cross-sectional study of insured workers in the chronic phase following mTBI was performed at a rehabilitation hospital in Ontario, Canada. Sociodemographic, occupational, injury-related, clinical, and claim-related data were collected from self-reports, medical assessments, and insurers’ referral files. Community Integration Questionnaire (CIQ) scores were compared using analysis of variance or Spearman’s correlation tests. Stepwise multivariable linear regression models were used to evaluate the associations with CI.

Results

Ninety-four workers with mTBI (45.2 ± 9.9 years old, 61.2 % male) at 197 days post-injury (interquartile range, 139–416 days) were included. The CIQ total and subscale scores were similar to those reported in more severe TBI samples. The CIQ scores were moderately to strongly correlated with various sociodemographic, claim-related, and clinical variables. In the multivariable regression analysis, several covariates accounted for 36.4 % of the CIQ variance in the final fully adjusted model.

Discussion

This study evaluated CI in workers with mTBI, and analyzed its associated variables. Analysis revealed insomnia, head or neck pain, being married or in a relationship, time since injury, and a diagnosis of possible/probable malingering were independently associated with limited CI.

Conclusions

Workers with delayed recovery from mTBI experience difficulty with CI. Insomnia is a particularly relevant covariate, explaining the greater part of its variance. To enhance participation, care should focus on clinical and non-clinical covariates.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-015-0432-z) contains supplementary material, which is available to authorized users.

The Diagnosis and Management of Concussion in Children and Adolescents

BACKGROUND

Concussion is a complex brain injury that results in more than 100,000 emergency department visits for school-aged children each year in the United States. All 50 US states have passed concussion legislation designed to promote safety in youth sports. Most of these laws require medical clearance by a licensed health care provider before returning to sport, which may have contributed to an increase in pediatric subspecialty referrals, particularly referrals to the child neurologist.

METHODS

We reviewed the literature on pediatric concussion.

RESULTS

This review summarizes the current knowledge and recommendations for concussion diagnosis and management in children and adolescents, athletes and nonathletes. It highlights concussion epidemiology, pathophysiology, advances in neuroimaging, and potential health risks including second impact syndrome and chronic traumatic encephalopathy. It also underscores clinical areas where evidence is lacking.

CONCLUSIONS

The diagnosis and management of concussion requires specific considerations in children. Further concussion research must be done to minimize injury risk and to optimize medical care for this common problem.