Predictors for Psychological Distress 2 Months After Mild Traumatic Brain Injury

Altered pattern of theta and gamma oscillation to visual stimuli in patients with postconcussion syndrome

Although many patients with mild traumatic brain injury (mTBI) suffer from postconcussional syndrome (PCS) including abnormal emotional responses, most conventional imaging studies fail to detect any causative brain lesion. We hypothesized that event-related electroencephalography (EEG) recordings with time-frequency analysis would show a distinguishable pattern in patients with mTBI with PCS compared with normal healthy controls. EEG signals were collected from a total of 18 subjects: eight patients with mTBI with PCS and 10 healthy control subjects. The signals were recorded while the subjects were presented with affective visual stimuli, including neutral, pleasant, and unpleasant emotional cues. Event-related spectral perturbation analysis was performed to calculate frontal midline theta activity and posterior midline gamma activity, followed by statistical analysis to identify whether patients with mTBI with PCS have distinct patterns of theta or gamma oscillations in response to affective stimuli. Compared with the healthy control group, patients with mTBI with PCS did not show a significant increase in the power of frontal theta activity in response to the pleasant stimuli, indicating less susceptibility toward pleasant cues. Moreover, the patient group showed attenuated gamma oscillatory activity, with no clear alteration in gamma oscillations in response to either pleasant or unpleasant cues. This study demonstrates that patients with mTBI with PCS exhibited altered patterns of oscillatory activities in the theta and gamma bands in response to affective visual stimuli compared with the normal control group. The current finding implicates that these distinguishable patterns of brain oscillation may represent the mechanism behind various psychiatric symptoms in patients with mTBI.NEW & NOTEWORTHY Patients with mild traumatic brain injury (mTBI) with postconcussional syndrome (PCS) exhibited altered patterns of changes in oscillatory activities in the theta and gamma bands in response to visual affective stimuli. Distinguishable patterns of brain oscillation may represent the mechanism behind various psychiatric symptoms in patients with mTBI.

Valued living after mild traumatic brain injury: Characteristics and relationship with outcomes

Psychological factors are strong predictors of mild traumatic brain injury (mTBI) recovery, consequently, psychological interventions can form part of an individual's rehabilitation. This may include enhancing valued living (VL), an approach that is effective in severe and mixed acquired brain injury samples. This study aimed to characterize VL in mTBI and explore its relationship with mTBI and mental health outcomes. 56 participants with a mTBI completed self-report measures before engaging in a psychological intervention. Pre-injury mental health and other demographic and injury-related variables, VL, post-concussion symptoms (PCS), functional disability, and stress, anxiety and depression were measured. A pre-injury mental health condition was significantly associated with VL. VL was uniquely associated with depression after mTBI (β = -0.08, p = .05), however, there was no relationship with PCS, functional disability, stress or anxiety (p > .05). Following mTBI individuals with a pre-injury mental health condition or who experience heightened depressive symptoms may benefit from a values-based intervention as part of their rehabilitation. Future research, however, is needed to examine the role of VL in mTBI recovery.

Acute Effects of Concussion in Adolescent Athletes With High Preseason Anxiety

OBJECTIVE

To examine associations between pre-existing anxiety symptoms, and symptoms and cognitive functioning acutely following a suspected concussion.

DESIGN

Nested case-control study.

SETTING

High schools in Maine, USA.

PARTICIPANTS

Participants were identified from a dataset of 46 920 student athletes ages 13 to 18 who received baseline preseason testing. A subset of 4732 underwent testing following a suspected concussion. Of those, 517 were assessed within 72 hours after their suspected concussion and met other inclusion criteria. Nineteen injured athletes endorsed anxiety-like symptoms on the Post-Concussion Symptom Scale (PCSS) during baseline testing and were placed in the high anxiety group. Each athlete was matched to 2 injured athletes who did not endorse high levels of anxiety-like symptoms (N = 57).

MAIN OUTCOME MEASURES

Immediate Post-Concussion Assessment and Cognitive Testing cognitive composite scores, PCSS total score, and symptom endorsement.

RESULTS

Cognitive composite scores were similar between groups across testing times ( = 0.004-0.032). The high anxiety group endorsed a greater number of symptoms than the low anxiety group ( = 0.452) and rated symptoms as more severe ( = 0.555) across testing times. Using a modified symptom score that excluded anxiety-like symptoms, a mixed analysis of variance indicated a group by injury interaction ( = 0.079); the high anxiety group reported greater increases in overall symptom severity following injury.

CONCLUSIONS

Adolescent athletes who have an anxious profile at baseline are likely to experience greater symptom burden following injury. Consideration of pre-injury anxiety may inform clinical concussion management by tailoring intervention strategies (eg, incorporating mental health treatments) to facilitate concussion recovery.

Improving Outcomes for Work-Related Concussions: A Mental Health Screening and Brief Therapy Model

OBJECTIVE

This study assessed the efficacy of a neurocognitive screening evaluation and brief therapy model to improve RTW outcomes for workers who experienced mild head injuries.

METHODS

Patients referred were evaluated using a neurocognitive and psychological screening battery. Work-focused cognitive behavioral therapy was provided when appropriate, addressing the role of negative emotional adjustment and functional sleep disturbance in prolonging recovery.

RESULTS

Average time to RTW was 7 weeks post-evaluation, despite workers being off an average of 10 months between injury and referral dates. Overall, 99% were released to full-duty work without restrictions or accommodations.

CONCLUSIONS

This study demonstrates the favorable outcomes achieved via a structured, clinically driven program for workers who experience head-involved injuries, validating previous research on the importance of recognizing the role of psychological factors in prolonging concussion recovery.

Analysis of Mild Traumatic Brain Injury Outpatient Follow-Up

BACKGROUND

Mild traumatic brain injury (mTBI) remains a prevalent public health concern. Implementation of an mTBI guideline encouraged screening all patients at risk for mTBI, followed by outpatient follow-up in a "concussion clinic." This resulted in an increase in inpatient concussion evaluations, followed by high-volume referral to the concussion clinic. This prompted the routine use of an outpatient mTBI symptom screening tool. The purpose of this quality improvement study was to analyze the characteristics of an mTBI population at outpatient follow-up and describe the clinicians' care recommendations as determined through the use of an mTBI symptom screening tool.

METHODS

This is a retrospective review of mTBI patients at a Level 1 trauma center. The study includes patients who completed a concussion screening in the outpatient setting over a 6-month period. Patients were included if older than 16 years, sustained blunt trauma, and had a formal neurocognitive evaluation by a certified speech therapist within 48 hr of initial injury.

RESULTS

Of the 247 patients included, 197 (79.8%) were referred to the concussion clinic, 33 (13.4%) had no further outpatient needs, and 17 (6.9%) were referred for outpatient neurocognitive rehabilitation. On follow-up, 97 patients were deemed to have no further postconcussion needs by the trauma nurse practitioner; 57 patients were cleared by the speech therapist. In total, 43 outpatient mTBI follow-up encounters resulted in referral for ongoing therapy.

CONCLUSION

Routine screening for concussion symptoms and detailed clinical evaluation allows for prompt recognition of further posttraumatic mTBI needs.

Perceived Change in Physical, Cognitive, and Emotional Symptoms after Mild Traumatic Brain Injury in Patients with Pre-Injury Anxiety or Depression

The objective of this study was to compare patients with acute-to-subacute mild traumatic brain injury (mTBI) on post-concussion symptom reporting based on whether they retrospectively recalled experiencing pre-injury anxiety or depression. Patients with mTBI (n = 297; 40.4% men; mean = 38.2 years old, standard deviation [SD] = 14.0, range = 17-65), referred from an emergency department in Taipei, Taiwan, were seen in a neurosurgical outpatient clinic on average 7.7 days since injury (SD = 5.7, range = 0 - 21 days), at which time they completed a checklist of post-concussion symptoms. Patients rated their current symptom severity and retrospectively rated their pre-injury symptom severity on 15 physical, cognitive, and emotional symptoms. Patients were grouped based on whether they did or did not have mild or greater pre-injury anxiety or depression based on this scale. Those with pre-injury anxiety or depression had greater pre-injury (all p's < 0.001, d range: 0.92-2.03) and post-injury (all p's < 0.001, d range: 0.65-1.00) symptom severity. However, when analyzing perceived change in symptoms (i.e., post-injury ratings minus pre-injury ratings), only perceived change in cognitive symptoms differed across groups (p = 0.018, d = 0.29), which became non-significant after controlling for gender. Greater post-concussion symptom severity in patients with pre-existing mental health problems may be mostly attributable to elevated symptoms before injury. These findings demonstrate the clinical value of retrospective pre-injury symptom assessment in mTBI management. Greater post-concussion symptom severity in patients with pre-injury mental health problems may represent a continuation of greater pre-injury symptom severity rather than a greater increase in symptom severity after mTBI.