Frequency and predictors of headache in the first 12 months after traumatic brain injury: results from CENTER-TBI

BACKGROUND

Headache is a prevalent and debilitating symptom following traumatic brain injury (TBI). Large-scale, prospective cohort studies are needed to establish long-term headache prevalence and associated factors after TBI. This study aimed to assess the frequency and severity of headache after TBI and determine whether sociodemographic factors, injury severity characteristics, and pre- and post-injury comorbidities predicted changes in headache frequency and severity during the first 12 months after injury.

METHODS

A large patient sample from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) prospective observational cohort study was used. Patients were stratified based on their clinical care pathway: admitted to an emergency room (ER), a ward (ADM) or an intensive care unit (ICU) in the acute phase. Headache was assessed using a single item from the Rivermead Post-Concussion Symptoms Questionnaire measured at baseline, 3, 6 and 12 months after injury. Mixed-effect logistic regression analyses were applied to investigate changes in headache frequency and associated predictors.

RESULTS

A total of 2,291 patients responded to the headache item at baseline. At study enrolment, 59.3% of patients reported acute headache, with similar frequencies across all strata. Female patients and those aged up to 40 years reported a higher frequency of headache at baseline compared to males and older adults. The frequency of severe headache was highest in patients admitted to the ICU. The frequency of headache in the ER stratum decreased substantially from baseline to 3 months and remained from 3 to 6 months. Similar trajectory trends were observed in the ICU and ADM strata across 12 months. Younger age, more severe TBI, fatigue, neck pain and vision problems were among the predictors of more severe headache over time. More than 25% of patients experienced headache at 12 months after injury.

CONCLUSIONS

Headache is a common symptom after TBI, especially in female and younger patients. It typically decreases in the first 3 months before stabilising. However, more than a quarter of patients still experienced headache at 12 months after injury. Translational research is needed to advance the clinical decision-making process and improve targeted medical treatment for headache.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02210221.

Exploring the Association between Personality Traits, Symptom Burden, and Return to Work after Mild-to-Moderate Traumatic Brain Injury

Approximately 30% of individuals with mild traumatic brain injury (mTBI) experience persistent post-concussion symptoms (PPCS). Personality factors have been linked to PPCS, yet, the association between personality traits and outcomes after mTBI is poorly understood. The aim of this study was to evaluate the association between personality traits, PPCS, and return to work (RTW) in patients with mild-to-moderate traumatic brain injury (TBI). Data from eighty-seven participants with mild-to-moderate TBI were analyzed. Sociodemographic, injury, and work characteristics and depressive symptoms were recorded 2-3 months post-injury. Personality traits were measured using the NEO Five-Factor Inventory-3. PPCS and RTW were assessed 15 months post-injury. Multiple linear regression models were performed. The factors associated with more severe PPCS were female sex, higher levels of neuroticism, openness to experience and conscientiousness, extra-cranial injuries, and depressive symptoms. The factors associated with lower RTW were female sex, higher levels of neuroticism, and conscientiousness. However, after controlling for PPCS, personality traits were no longer significantly associated with RTW. In conclusion, specific personality traits were associated with more severe PPCS and may be indirectly associated with RTW via PPCS. Hence, personality traits may be important to assess to identify patients at risk of less favorable outcomes after mild-to-moderate TBI.

Workplace Factors Associated With Return to Work After Mild-to-Moderate Traumatic Brain Injury

OBJECTIVE

Sociodemographic and injury-related predictors for return to work (RTW) after mild-to-moderate traumatic brain injury (TBI) have been extensively explored. However, there is a knowledge gap regarding work-related predictors of RTW. The main aim of this study was to explore work-related predictors of work participation 6 and 12 months after mild-to-moderate TBI.

SETTING

Data were collected at baseline 8 to 12 weeks after injury, and 3, 6, and 12 months after baseline, at a specialized TBI rehabilitation outpatient clinic at Oslo University Hospital, Oslo, Norway.

PARTICIPANTS

Eligible patients had suffered a mild-to-moderate TBI 8 to 12 weeks previously, were employed 50% or more at time of injury, were between 18 and 60 years of age, and sick listed 50% or more at time of inclusion due to symptoms of TBI (based on the Rivermead Post-Concussion Symptoms Questionnaire). In total, 116 patients were included in a randomized controlled trial, of whom 113 were included in the 1-year analysis.

DESIGN

Patients were originally included in a randomized controlled trial. There were no between-group differences in RTW after 1 year. Thus, the participants were evaluated as one cohort in this study.

MAIN MEASURES

The primary outcome measure was work participation 1 year after study inclusion. Work-related predictors were chosen on the basis of previous research and expert opinion and entered into a multivariable linear regression model. The model controlled for sociodemographic and injury-related factors.

RESULTS

The best-fitting model explained 25% of variation in work participation at 1 year. Significant predictors were predictability, quantitative demands and rewards (recognition) at the workplace, private or public employment, symptom burden at baseline, and sex.

CONCLUSION

In this study, several work-related predictors outperformed some of the established sociodemographic and injury-related predictors of RTW after TBI, thus stressing the need for further focus and research on amendable predictors of RTW after mild-to-moderate TBI.

Rehabilitation and outcomes after complicated vs uncomplicated mild TBI: results from the CENTER-TBI study

BACKGROUND

Despite existing guidelines for managing mild traumatic brain injury (mTBI), evidence-based treatments are still scarce and large-scale studies on the provision and impact of specific rehabilitation services are needed. This study aimed to describe the provision of rehabilitation to patients after complicated and uncomplicated mTBI and investigate factors associated with functional outcome, symptom burden, and TBI-specific health-related quality of life (HRQOL) up to six months after injury.

METHODS

Patients (n = 1379) with mTBI from the Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study who reported whether they received rehabilitation services during the first six months post-injury and who participated in outcome assessments were included. Functional outcome was measured with the Glasgow Outcome Scale - Extended (GOSE), symptom burden with the Rivermead Post Concussion Symptoms Questionnaire (RPQ), and HRQOL with the Quality of Life after Brain Injury - Overall Scale (QOLIBRI-OS). We examined whether transition of care (TOC) pathways, receiving rehabilitation services, sociodemographic (incl. geographic), premorbid, and injury-related factors were associated with outcomes using regression models. For easy comparison, we estimated ordinal regression models for all outcomes where the scores were classified based on quantiles.

RESULTS

Overall, 43% of patients with complicated and 20% with uncomplicated mTBI reported receiving rehabilitation services, primarily in physical and cognitive domains. Patients with complicated mTBI had lower functional level, higher symptom burden, and lower HRQOL compared to uncomplicated mTBI. Rehabilitation services at three or six months and a higher number of TOC were associated with unfavorable outcomes in all models, in addition to pre-morbid psychiatric problems. Being male and having more than 13 years of education was associated with more favorable outcomes. Sustaining major trauma was associated with unfavorable GOSE outcome, whereas living in Southern and Eastern European regions was associated with lower HRQOL.

CONCLUSIONS

Patients with complicated mTBI reported more unfavorable outcomes and received rehabilitation services more frequently. Receiving rehabilitation services and higher number of care transitions were indicators of injury severity and associated with unfavorable outcomes. The findings should be interpreted carefully and validated in future studies as we applied a novel analytic approach.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02210221.

Workplace accommodation in return to work after mild traumatic brain injury

BACKGROUND: While a vast amount of research focuses on unmodifiable and individual factors that may impact return to work (RTW) for patients with traumatic brain injury (TBI), less knowledge exists of the relationship between specific workplace factors and work retention. OBJECTIVE: Identify types of accommodation in the workplace that influence the RTW process for employees with TBI and the challenges associated with them. METHODS: A multiple case study consisting of 38 cases and 109 interviews of employees with TBI and their managers conducted between 2017 and 2020 at two time points. RESULTS: Accommodation of both the organizational and psychosocial work environment influences RTW for employees with TBI. Social support and supportive management may have positive and negative effects. RTW is often not a linear process. Over time, maintaining and developing customized accommodation in the work organization is challenging. CONCLUSIONS: Uncertainty about accommodation in RTW for employees with TBI is closely linked to lack of knowledge in the workplace of how to handle complex and nonlinear RTW processes. Work-oriented rehabilitation should to a greater extent provide managers with relevant information and support to develop the person-environment fit over time.

Transition back to work after mild TBI: a qualitative study

BACKGROUND

While many persons who sustain a mild traumatic brain injury (MTBI) can resume work shortly after their injury, some experience persisting symptoms leading to longer-term sickness absence. In-depth knowledge about how these persons experience the return to work (RTW) process is needed.

AIMS

To explore how persons with MTBI experience the process of returning to ordinary competitive work after a prolonged period of sickness absence.

MATERIAL AND METHODS

Semi-structured interviews were conducted with six persons (four women) approximately 12 months after sustaining an MTBI. Data were analysed using a stepwise-deductive inductive method.

RESULTS

When starting work the participants experienced a crisis. They described the importance of making the actual decision to RTW. Being present at the workplace was significant. In the process of increased workload, they expressed having challenges related to time perception and capacity restrictions. The importance of being seen and valued was emphasised. When reintegrated into the workplace revaluing work tasks and priorities shaped the RTW process as well as a further professional career.

CONCLUSIONS AND SIGNIFICANCE

The process of RTW contained the experience of unpredictability and incompatibility with own identity and performance. Working had an impact on social participation, self-worth, daily structure, as well as reconstructing occupational biography.

"Manoeuvring in uncharted waters - a balancing act": A qualitative exploration of treatment and improvement after mild traumatic brain injury

Background: Individuals who have sustained mild traumatic brain injury (mTBI) with a protracted course of recovery may experience long-lasting somatic, cognitive, and emotional symptoms affecting activities of daily living. There is limited knowledge regarding individuals' lived experiences with treatments and advice provided.Purpose: To explore how individuals with mTBI describe and make sense of their injury, recovery process, and their experiences with various treatment approaches.Methods: Eight participants with mTBI were recruited from the intervention group in an ongoing randomized controlled trial regarding return-to-work. They were interviewed once after treatment delivery using a qualitative hermeneutical approach. Thematic analysis was applied, and findings are discussed in light of a salutogenic theory.Results: Participants expressed uncertainty regarding conflicting advice they received in the early phase of recovery. Three main themes were developed: (1) "Ambiguity and hope"; (2) "Uncertainty concerning activity and rest"; and (3) "To become the person I used to be vs. to become a new version of myself."Conclusion: The findings showed that the participants experienced both uncertainty and hope for further recovery. The recovery process is challenged by the variability of TBI symptoms that affects participation in everyday life, as well as the conflicting advice received by the participants.

Post-concussion symptoms three months after mild-to-moderate TBI: characteristics of sick-listed patients referred to specialized treatment and consequences of intracranial injury

Objective: To present pre-injury, injury-related, work-related and post-injury characteristics, and to compare patients with and without traumatic intracranial abnormalities, in a treatment-seeking sample with persistent post-concussion symptoms (PPCS) after mild-to-moderate TBI.Methods: Cross-sectional design in the context of a specialized TBI outpatient clinic. Eligible patients were aged 18-60 years, employed ≥ 50% at time of injury, and sick listed ≥ 50% at inclusion due to PPCS. Data were collected 8-12 weeks after injury through review of medical records, semi-structured interviews, questionnaires, and neuropsychological screening.Results: The study included 116 patients, of whom 60% were women, and predominantly white-collar workers in full-time positions. Ninety-four percent had a mild TBI, and 23% had intracranial abnormalities. The full sample reported high somatic, emotional, and cognitive symptom burden, and decreased health-related quality of life. Patients with normal CT/MRI results reported higher overall symptom burden, while patients with intracranial abnormalities had worse memory function.Conclusion: Injury severity and traumatic intracranial radiological findings should not be the sole ground for planning of rehabilitation service provision in patients with PPCS, as subjective complaints do not necessarily co-vary with these variables.

Cognitive and vocational rehabilitation after mild-to-moderate traumatic brain injury: A randomised controlled trial

BACKGROUND

Returning to work is often a primary rehabilitation goal after traumatic brain injury (TBI). However, the evidence base for treatment options regarding return to work (RTW) and stable work maintenance remains scarce.

OBJECTIVE

This study aimed to examine the effect of a combined cognitive and vocational intervention on work-related outcomes after mild-to-moderate TBI.

METHODS

In this study, we compared 6 months of a combined compensatory cognitive training and supported employment (CCT-SE) intervention with 6 months of treatment as usual (TAU) in a randomised controlled trial to examine the effect on time to RTW, work percentage, hours worked per week and work stability. Eligible patients were those with mild-to-moderate TBI who were employed ≥50% at the time of injury, 18 to 60 years old and sick-listed ≥50% at 8 to 12 weeks after injury due to post-concussion symptoms, assessed by the Rivermead Post Concussion Symptoms Questionnaire. Both treatments were provided at the outpatient TBI department at Oslo University Hospital, and follow-ups were conducted at 3, 6 and 12 months after inclusion.

RESULTS

We included 116 individuals, 60 randomised to CCT-SE and 56 to TAU. The groups did not differ in characteristics at the 12-month follow-up. Overall, a high proportion had returned to work at 12 months (CCT-SE, 90%; TAU, 84%, P=0.40), and all except 3 were stably employed after the RTW. However, a significantly higher proportion of participants in the CCT-SE than TAU group had returned to stable employment at 3 months (81% vs. 60%, P=0.02).

CONCLUSION

These results suggest that the CCT-SE intervention might help patients with mild-to-moderate TBI who are still sick-listed 8 to 12 weeks after injury in an earlier return to stable employment. However, the results should be replicated and a cost-benefit analysis performed before concluding.

Effectiveness of Combining Compensatory Cognitive Training and Vocational Intervention vs. Treatment as Usual on Return to Work Following Mild-to-Moderate Traumatic Brain Injury: Interim Analysis at 3 and 6 Month Follow-Up

Aims: Knowledge regarding the most effective return to work (RTW) approaches after traumatic brain injury (TBI) is lacking. This trial aimed to compare the effectiveness of a combined cognitive and vocational intervention to treatment as usual (TAU) on RTW and work stability after TBI.

Methods: We performed a parallel-group randomized controlled trial (RCT) at a TBI outpatient clinic at Oslo University Hospital (OUH), Norway. Patients with a history of mild-to-moderate TBI (n = 116) aged 18–60 were randomized (1:1) by an independent investigator to receive group-based compensatory cognitive training (CCT) and supported employment (SE) (n = 60) or TAU consisting of individualized multidisciplinary treatment (n = 56). Participants were enrolled 2–3 months post-injury. The nature of the intervention prevented blinding of patients and therapists, however, outcome assessors were blinded to group allocation. The primary outcome measure was RTW at 3 and 6 months following study inclusion. Secondary outcomes were work percentage, stability, and productivity. The present study provides results from an interim analysis from the first two planned follow ups, while subsequent publications will present results up to 12 months following study inclusion.

Results: Mixed effects models showed no between-group differences in the RTW proportion, work percentage, and hours worked between CCT-SE and TAU from baseline to 6 months. A significantly higher proportion of participants in CCT-SE had returned to work at 3 months when adjusting for baseline differences. The majority of participants who were employed at 3 and 6 months were stably employed. There was a statistically significant within-group improvement on RTW proportion, hours worked and work percentage in both groups.

Conclusion: The results revealed no difference between CCT-SE and TAU on work-related outcomes from baseline to 6 months. However, there was a higher RTW proportion in the CCT-SE group compared to TAU at 3 months. Future publications will assess the effectiveness of CCT-SE vs. TAU up to 12 months.

Clinical Trial Registration: US National Institutes of Health ClinicalTrials.gov, identifier #NCT03092713.

Early Predictors of Employment Status One Year Post Injury in Individuals with Traumatic Brain Injury in Europe

Sustaining a traumatic brain injury (TBI) often affects the individual’s ability to work, reducing employment rates post-injury across all severities of TBI. The objective of this multi-country study was to assess the most relevant early predictors of employment status in individuals after TBI at one-year post-injury in European countries. Using a prospective longitudinal non-randomized observational cohort (The Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) project), data was collected between December 2014–2019 from 63 trauma centers in 18 European countries. The 1015 individuals who took part in this study were potential labor market participants, admitted to a hospital and enrolled within 24 h of injury with a clinical TBI diagnosis and indication for a computed tomography (CT) scan, and followed up at one year. Results from a binomial logistic regression showed that older age, status of part-time employment or unemployment at time of injury, premorbid psychiatric problems, and higher injury severity (as measured with higher Injury severity score (ISS), lower Glasgow Coma Scale (GCS), and longer length of stay (LOS) in hospital) were associated with higher unemployment probability at one-year after injury. The study strengthens evidence for age, employment at time of injury, premorbid psychiatric problems, ISS, GCS, and LOS as important predictors for employment status one-year post-TBI across Europe.

What characterises work and workplaces that retain their employees following acquired brain injury? Systematic review

OBJECTIVES

The objective of this study was to conduct a systematic review assessing workplace factors related to work retention (or return to work) in employees with acquired brain injury (ABI). Additionally, we aimed to synthesise the evidence and state of knowledge on this subject.

METHODS

A database search was performed in nine relevant electronic databases. Inclusion criteria were quantitative peer-reviewed publications empirically investigating the relationship between work/workplace factors and work retention in employees following ABI. The methodological quality was determined by Effective Public Health Practice Project scoring, and evidence was synthesised narratively.

RESULTS

Thirteen studies were included. We found moderate evidence for a negative relationship between manual work and work retention. We also found limited evidence for a U-shaped relationship between workload and complete work retention at 6 months and no relationship at 12 months; a positive relationship between managers, compared with non-managers, and faster work retention; a positive relationship between large enterprise size defined as ≥250 employees, and no relationship between large enterprise size, defined as ≥1000 employees, and work retention.

CONCLUSION

Relative to individual factors, there is little evidence on specific workplace factors' relationship to work retention among employees with ABI. For most workplace factors, there were too few high-quality studies to designate evidence as more than limited or insufficient. Future studies should replicate rigorous studies of well-defined modifiable workplace factors related to work retention.

PROSPERO REGISTRATION NUMBER

CRD42018082201.

Randomized Controlled Trials of Rehabilitation Services in the Post-acute Phase of Moderate and Severe Traumatic Brain Injury - A Systematic Review

Background and aims: There is a gap in knowledge regarding effective rehabilitation service delivery in the post-acute phase after traumatic brain injury (TBI). Recently, Gutenbrunner et al. proposed a classification system for health-related rehabilitation services (International Classification System for Service Organization in Health-related Rehabilitation, ICSO-R) that could be useful for contrasting and comparing rehabilitation services. The ICSO-R describes the dimensions of Provision (i.e., context of delivered services), Funding (i.e., sources of income and refunding), and Delivery (i.e., mode, structure and intensity) at the meso-level of services.

We aim to:

-Provide an overview of randomized, controlled trials (RCTs) with rehabilitation service relevance provided to patients with moderate and severe TBI in the post-acute phase using the ICSO-R as a framework; and

-Evaluate the extent to which the provision, funding and delivery dimensions of rehabilitation services were addressed and differed between the intervention arms in these studies.

Materials and methods: A systematic literature search was performed in OVID MEDLINE, EMBASE, CINHAL, PsychINFO, and CENTRAL, including multidisciplinary rehabilitation interventions with RCT designs and service relevance targeting moderate and severe TBI in the post-acute phase.

Results: 23 studies with 4,644 TBI patients were included. More than two-thirds of the studies were conducted in a hospital-based rehabilitation setting. The contrast in Context between the intervention arms often co-varied with Resources. The funding of the services was explicitly described in only one study. Aspects of the Delivery dimension were described in all of the studies, and the Mode of Production, Intensity, Aspects of Time and Peer Support were contrasted in the intervention arms in several of the studies. A wide variety of outcome measures were applied often covering Body function, as well as the Activities and Participation domains of the International Classification of Functioning, Disability, and Health (ICF).

Conclusion: Aspects of service organization and resources as well as delivery may clearly influence outcome of rehabilitation. Presently, lack of uniformity of data and collection methods, the heterogeneity of structures and processes of rehabilitation services, and a lack of common outcome measurements make comparisons between the studies difficult. Standardized descriptions of services by ICSO-R, offer the possibility to improve comparability in the future and thus enhance the relevance of rehabilitation studies.