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Mikolic A, Klotz T, Brasher P, Yeates K, Vranceanu AM, Kendall KD, Snell DL, Debert CT, Bayley M, Panenka W, Cairncross M, Hunt C, Burke M, Tartaglia MC, Silverberg N. Graded Exposure Therapy for Fear Avoidance Behaviour After Concussion (GET FAB): protocol for a multisite Canadian randomised controlled trial. BMJ Open 2024; 14:e086602. [PMID: 38950993 PMCID: PMC11218021 DOI: 10.1136/bmjopen-2024-086602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 06/12/2024] [Indexed: 07/03/2024] Open
Abstract
INTRODUCTION Persistent symptoms after mild traumatic brain injury (mTBI) negatively affect daily functioning and quality of life. Fear avoidance behaviour, a coping style in which people avoid or escape from activities or situations that they expect will exacerbate their symptoms, maybe a particularly potent and modifiable risk factor for chronic disability after mTBI. This study will evaluate the efficacy of graded exposure therapy (GET) for reducing persistent symptoms following mTBI, with two primary aims: (1) To determine whether GET is more effective than usual care; (2) to identify for whom GET is the most effective treatment option, by evaluating whether baseline fear avoidance moderates differences between GET and an active comparator (prescribed aerobic exercise). Our findings will guide evidence-based care after mTBI and enable better matching of mTBI patients to treatments. METHODS AND ANALYSIS We will conduct a multisite randomised controlled trial with three arms. Participants (n=220) will be recruited from concussion clinics and emergency departments in three Canadian provinces and randomly assigned (1:2:2 ratio) to receive enhanced usual care, GET or prescribed aerobic exercise. The outcome assessment will occur remotely 14-18 weeks following baseline assessment, after completing the 12-week treatment phase. The primary outcome will be symptom severity (Rivermead Post-concussion Symptoms Questionnaire). ETHICS AND DISSEMINATION Informed consent will be obtained from all participants. All study procedures were approved by the local research ethics boards (University of British Columbia Clinical Research Ethics Board, University of Calgary Conjoint Health Research Ethics Board, University Health Network Research Ethics Board-Panel D). Operational approvals were obtained for Vancouver Coastal Health Research Institute and Provincial Health Services Authority. If GET proves effective, we will disseminate the GET treatment manual and present instructional workshops for clinicians. TRIAL REGISTRATION NUMBER ClinicalTrials.gov #NCT05365776.
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Affiliation(s)
- Ana Mikolic
- Department of Psychology, The University of British Columbia, Vancouver, British Columbia, Canada
- Rehabilitation Research Program, Centre for Aging SMART, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Tasha Klotz
- Department of Psychology, The University of British Columbia, Vancouver, British Columbia, Canada
- Rehabilitation Research Program, Centre for Aging SMART, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Penelope Brasher
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Keith Yeates
- Department of Psychology, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, Univeristy of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Ana-Maria Vranceanu
- Department of Psychiatry, Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Karen D Kendall
- School of Kinesiology, Acadia University, Wolfville, Nova Scotia, Canada
| | - Deborah L Snell
- Department of Orthopedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch, New Zealand
| | - Chantel T Debert
- Alberta Children's Hospital Research Institute, Univeristy of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, Univeristy of Calgary, Calgary, Alberta, Canada
| | - Mark Bayley
- Hull-Ellis Concussion Clinic, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Division of Physical Medicine and Rehabilitation, Temerty Medicine, University of Toronto, Toronto, Ontario, Canada
| | - William Panenka
- Department of Psychiatry, UBC, Vancouver, British Columbia, Canada
- British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, British Columbia, Canada
- British Columbia Provincial Neuropsychiatry Program, Vancouver, British Columbia, Canada
| | - Molly Cairncross
- Department of Psychology, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Cindy Hunt
- Head Injury Clinic, Department of Trauma and Neurosurgery, St Michael's Hospital, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Concussion Ontario Network: Neuroinformatics to Enhance Clinical Care and Translation, Toronto, British Columbia, Canada
| | - Matthew Burke
- Neuropsychiatry Program, Department of Psychiatry and Division of Neurology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Hurvitz Brain Sciences Program and Tory Trauma Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Maria Carmela Tartaglia
- Tanz Centre for Research in Neurodegenerative Diseases, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Noah Silverberg
- Department of Psychology, The University of British Columbia, Vancouver, British Columbia, Canada
- Rehabilitation Research Program, Centre for Aging SMART, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
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Wang Z, Xu L, Xu Y, Huang Y, Sharma A, Sharma HS. Efficacy and safety of acupuncture in the treatment of post-traumatic headache secondary to mild traumatic brain injury: A systematic evaluation and meta-analysis protocol of randomized controlled trials. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2023; 171:317-327. [PMID: 37783561 DOI: 10.1016/bs.irn.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
INTRODUCTION Post-traumatic headache secondary to mild traumatic brain injury in patients has become an important factor in their prognosis. Due to the lack of effective pharmacological treatments, non-pharmacological interventions such as acupuncture are considered to have greater potential. However, the efficacy and safety of acupuncture treatment have not been clearly demonstrated. The purpose of this meta-analysis protocol is to investigate the effectiveness and safety of acupuncture in the treatment of headache secondary to mild traumatic brain injury. METHODS AND ANALYSIS Seven English and Chinese databases will be selected and searched according to their respective search methods, spanning the period from database creation to April 2022, and the languages will be limited to English and Chinese. Only randomized controlled trials will be included. Study selection, data collection, and risk of bias control will be performed by two independent investigators. Any disagreements will be referred to a third independent investigator for decision and documentation. Revman software will be used to complete our meta-analysis, and risk of bias assessment, subgroup analysis, and sensitivity analysis will be performed to correct the results. Finally we will assess the reliability of our final results using the Recommended Guidelines Development Tool for Assessment. ETHICS AND DISSEMINATION All data for this study will be obtained from published journals, so no ethical review will be required. The completed review will be published in a peer-reviewed journal and the findings will be further disseminated through presentation at an appropriate forum or conference.
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Affiliation(s)
- Zhe Wang
- Linping Hospital of Traditional Chinese Medicine, Hangzhou City, Zhejiang Province, China
| | - Longbiao Xu
- Department of Neurosurgery, The Third Affiliated Hospital of Zhejiang Chinese Medical University, P.R. China
| | - Yujie Xu
- The Third Affiliated Hospital of Zhejiang Chinese Medical University, P.R. China
| | - Yubo Huang
- The Third School of Clinical Medicine, Zhejiang Chinese Medical University, P.R. China
| | - Aruna Sharma
- International Experimental Central Nervous System Injury & Repair (IECNSIR), Dept. 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), Dept. of Surgical Sciences, Anesthesiology & Intensive Care Medicine, Uppsala University Hospital, Uppsala University, Uppsala, Sweden.
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Blumenfeld A, McVige J, Knievel K. Post-traumatic headache: Pathophysiology and management - A review. JOURNAL OF CONCUSSION 2022. [DOI: 10.1177/20597002221093478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Post-traumatic headache (PTH) is a common secondary headache due to traumatic brain injury. In the past, significant research has been conducted to understand the pathophysiology and treatment options for PTH. However, PTH still lacks evidence-based treatment, and most of the management depends on the primary phenotype observed in the patient. Objective The main objective of this review is to provide a single reference that covers the current understanding of the pathophysiology and the treatment options available for PTH. Methods A detailed literature search on PubMed was performed, and a narrative review was prepared. Results The pathophysiology of PTH is multifactorial. Acute PTH may be attributed to increased peripheral pain sensitization with impaired pain inhibiting pathways. Chronic or persistent PTH may be due to a chronic inflammatory response and peripheral as well as central sensitization. The mechanism responsible for the transition of acute to persistent PTH is unknown. The migraine-like phenotype is reported to be the most prevalent headache type seen in PTH. New targets for preventive treatment have been identified in recent years, such as neuropeptides like calcitonin-gene-related peptide (CGRP), nitric oxide, and glutamate. The preventive pharmacological and non-pharmacological strategies employed for migraine (e.g. anti-CGRP monoclonal antibodies, onabotulinumtoxinA, physical therapy, cognitive and behavioral treatment, and neurostimulation techniques) have shown in preliminary studies that they are potentially efficacious, but large, randomized, double blind, placebo controlled trials are needed to further establish these as treatment options for PTH. Conclusions The lack of evidence-based treatment for PTH has created a need for future large trials to confirm the safety and efficacy of the currently employed treatments.
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Affiliation(s)
- Andrew Blumenfeld
- The Los Angeles Headache Center and The San Diego Headache Center, Los Angeles, CA, USA
| | | | - Kerry Knievel
- Barrow Neurological Institute, Phoenix, Arizona, USA
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Mollica A, Dey A, Cairncross M, Silverberg N, Burke MJ. Neuropsychiatric Treatment for Mild Traumatic Brain Injury: Nonpharmacological Approaches. Semin Neurol 2022; 42:168-181. [PMID: 35114694 DOI: 10.1055/s-0041-1742143] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Postconcussive symptoms following mild traumatic brain injury (mTBI)/concussion are common, disabling, and challenging to manage. Patients can experience a range of symptoms (e.g., mood disturbance, headaches, insomnia, vestibular symptoms, and cognitive dysfunction), and neuropsychiatric management relies heavily on nonpharmacological and multidisciplinary approaches. This article presents an overview of current nonpharmacological strategies for postconcussive symptoms including psychoeducation; psychotherapy; vestibular, visual, and physical therapies; cognitive rehabilitation; as well as more novel approaches, such as neuromodulation. Ultimately, treatment and management of mTBI should begin early with appropriate psychoeducation/counseling, and be tailored based on core symptoms and individual goals.
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Affiliation(s)
- Adriano Mollica
- Neuropsychiatry Program, Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.,Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Ayan Dey
- Neuropsychiatry Program, Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.,Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Molly Cairncross
- Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada.,Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Noah Silverberg
- Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada.,Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Matthew J Burke
- Neuropsychiatry Program, Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.,Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Abstract
PURPOSE OF REVIEW To discuss the treatment of post-traumatic headache (PTH) and how to choose pharmacotherapy based upon known pathophysiology. RECENT FINDINGS Preclinical models of traumatic brain injury are finally revealing some of the mechanisms of PTH, including the significant role that inflammatory neuropeptides like calcitonin gene-related peptide (CGRP) play in the initiation and persistence of symptoms. To effectively treat post-traumatic headache (PTH), one needs to understand the pathophysiology behind the initiation and persistence of symptoms. Recent animal models are starting to elucidate these mechanisms, but effective treatment will also likely rely on the identification of patients who are most at risk for persistent PTH. Trials of early, targeted therapy for at-risk patients will be needed to validate these hypotheses. Additionally, high powered clinical trials are lacking in the field of persistent PTH for medications that are known to be effective in primary headache disorders. Effective treatment for persistent PTH also requires understanding how headache interacts with the complex nature of persistent post-concussion symptoms, as this disease often necessitates a multi-disciplinary approach. Regardless, with the knowledge gained by new PTH models cited in this paper, and an increasing availability of novel headache medications, more effective treatment models are on the horizon.
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Affiliation(s)
- Joshua Kamins
- Goldberg Migraine Program, Department of Neurology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA.
- Steve Tisch BrainSPORT Program, Department of Neurosurgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA.
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Argyriou AA, Mitsikostas DD, Mantovani E, Litsardopoulos P, Panagiotopoulos V, Tamburin S. An updated brief overview on post-traumatic headache and a systematic review of the non-pharmacological interventions for its management. Expert Rev Neurother 2021; 21:475-490. [PMID: 33682560 DOI: 10.1080/14737175.2021.1900734] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Post-traumatic headache (PTH), a common type of headache secondary to traumatic brain injury (TBI) or whiplash, carries a relevant burden on patients. PTH is still an undertreated condition because of limited pharmacological treatment options. Therefore, multimodal non-pharmacologic approaches, which account for comorbidities and biopsychosocial factors, are often used in PTH patients. AREAS COVERED After providing a brief overview of PTH, a systematic review was conducted, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations on recently published (2015-2020) papers on non-pharmacological interventions for PTH. We also collected data on ongoing trials on this topic. Studies and results are reviewed and discussed. EXPERT OPINION PTH is one of the most common complications of TBI and accounts for almost 4% of symptomatic headache disorders. The most common clinical presentations of PTH are migraine-like or tension type (TTH)-like headache, neck pain, cognitive complaints, and psychological/psychiatric symptoms. Growing evidence suggests that combined pharmacological and non-pharmacological interventions, encompassing noninvasive neuromodulation, physical therapy, cognitive-behavioral treatment, and education, may be the best approaches for PTH and related comorbidities. Acute/preemptive pharmacological treatments for PTH include drugs used for migraine and TTH. When PTH management is multidisciplinary, the patient benefits most.
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Affiliation(s)
- Andreas A Argyriou
- Headache Outpatient Clinic, Department of Neurology, Saint Andrew's State General Hospital of Patras, Greece
| | - Dimos-Dimitrios Mitsikostas
- 1st Department of Neurology, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Elisa Mantovani
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Pantelis Litsardopoulos
- Headache Outpatient Clinic, Department of Neurology, Saint Andrew's State General Hospital of Patras, Greece
| | | | - Stefano Tamburin
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
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Guglielmetti M, Serafini G, Amore M, Martelletti P. The Relation between Persistent Post-Traumatic Headache and PTSD: Similarities and Possible Differences. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17114024. [PMID: 32516965 PMCID: PMC7313050 DOI: 10.3390/ijerph17114024] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/11/2020] [Accepted: 05/26/2020] [Indexed: 12/27/2022]
Abstract
Post-traumatic headache (PTH) may be considered a secondary headache, which is linked to severe disability and psychosocial impairment. Interestingly, nearly 30% of subjects with persistent post-traumatic headache (PPTH) also suffer from post-traumatic stress disorder (PTSD). Although existing studies demonstrated the existence of common pathophysiological characteristics in subjects with migraine and PPTH, the differences and similarities between these complex diseases are currently poorly understood and are yet to be comprehensively elucidated. Thus, the present review aimed to systematically investigate the nature of PPTH in the effort to better identify both the neurobiological and clinical aspects underlying this condition. Overall, the included studies reported that: (1) the predictors for persistent acute traumatic injury to the head were female gender, persistent symptoms related to mild post-traumatic brain injury (mTBI), PTSD, elevated inflammatory markers, prior mild traumatic brain injury, being injured while suffering from alcohol abuse; (2) static/dynamic functional connectivity differences, white matter tract abnormalities, and morphology changes were found between PPTH and migraine in brain regions involved in pain processing; and (3) clinical differences which were most prominent at early time points when they were linked to the increased risk of PPTH. Based on the selected reports, the relation between migraine and PPTH needs to be considered bidirectionally, but PTSD may play a critical role in this relation. The main implications of these findings, with a specific focus on PTSD, are discussed. Further longitudinal studies are needed to reveal the exact nature of this relation, as well as to clarify the distinct clinical characteristics of migraine, PPTH, and PTSD.
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Affiliation(s)
- Martina Guglielmetti
- Sant’Andrea Hospital, Regional Referral Headache Centre, 00181 Rome, Italy; (M.G.); (P.M.)
- Department of Clinical and Molecular Medicine, Sapienza University, 00181 Rome, Italy
| | - Gianluca Serafini
- Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics and Maternal Childhood Sciences, Psychiatry Unit, University of Genoa, 16132 Genoa, Italy;
- IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy
- Correspondence: ; Tel.: +39-010-353-7668 (office); +39-347-537-2316 (mobile); Fax: +39-010-353-7669
| | - Mario Amore
- Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics and Maternal Childhood Sciences, Psychiatry Unit, University of Genoa, 16132 Genoa, Italy;
- IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy
| | - Paolo Martelletti
- Sant’Andrea Hospital, Regional Referral Headache Centre, 00181 Rome, Italy; (M.G.); (P.M.)
- Department of Clinical and Molecular Medicine, Sapienza University, 00181 Rome, Italy
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Belanger HG, Wortzel HS, Vanderploeg RD, Cooper DB. A model for intervening with veterans and service members who are concerned about developing Chronic Traumatic Encephalopathy (CTE). Clin Neuropsychol 2019; 34:1105-1123. [DOI: 10.1080/13854046.2019.1699166] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Heather G. Belanger
- Defense and Veterans Brain Injury Center, Silver Spring, MD, USA
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida, Tampa, FL, USA
- Department of Psychology, University of South Florida, Tampa, FL, USA
- James A, Haley Veterans Hospital, United States Special Operations Command, 9Line LLC, Tampa, FL, USA
| | - Hal S. Wortzel
- Rocky Mountain MIRECC, Rocky Mountain Regional Medical Center, Aurora, CO, USA
- Departments of Psychiatry, Neurology, and PM&R, University of Colorado, Aurora, CO, USA
| | - Rodney D. Vanderploeg
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida, Tampa, FL, USA
- Department of Psychology, University of South Florida, Tampa, FL, USA
| | - Douglas B. Cooper
- Defense and Veterans Brain Injury Center, Silver Spring, MD, USA
- Polytrauma Rehabilitation Center, Audie Murphy Memorial VA Hospital, San Antonio, TX, USA
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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