Incidence of Postconcussion Symptoms in Psychiatric Diagnostic Groups, Mild Traumatic Brain Injury, and Comorbid Conditions

Enhanced vocational rehabilitation for Veterans with mild traumatic brain injury and mental illness: Pilot study

Work plays a significant role in how people identify themselves, and successful return to work is associated with significant psychological and rehabilitative benefits. Unfortunately, despite the many benefits of employment, Veterans who experience mild traumatic brain injury and have mental health issues often have significant difficulty getting their vocational needs met. Considering that a consistent relationship between cognitive dysfunction and difficulties with employability has been firmly established, cognitive rehabilitation may enhance engagement in vocational rehabilitation and return to work outcomes. In this pilot study, we evaluated a 12 wk cognitive rehabilitation intervention embedded within vocational rehabilitation services. Eighteen Veterans were randomly assigned to receive either the embedded cognitive rehabilitation intervention (n = 10) or a control condition offering supportive client-centered therapy that did not focus on employment or cognitive rehabilitation (n = 8); all Veterans (intervention and control groups) received vocational rehabilitation services. This pilot feasibility study demonstrated efficient implementation of an embedded cognitive rehabilitation intervention within vocational rehabilitation. The current pilot data revealed small to moderate effect sizes on employment outcomes. Given these preliminary findings, a larger outcome study is warranted.

Prospective Analysis of Premilitary Mental Health, Somatic Symptoms, and Postdeployment Postconcussive Symptoms

OBJECTIVES

Many recent studies of service members returning from deployment have focused on the health impacts of mild traumatic brain injury (mTBI), including persistent postconcussive symptoms (PCS). However, cross-sectional study designs have made it difficult to understand the role of mental health in the etiology of persistent PCS.

METHODS

Participants were 3319 military personnel (primarily men [90%] of 25-34 years [54%]) who had completed health surveys at basic training and after deployment, on average, 4.6 years later. Negative binomial regression was used to assess the association of PCS with demographic covariates, premilitary mental health and somatic symptoms, combat experiences and mTBI during deployment, in addition to postdeployment mental health and non-PCS somatic symptoms.

RESULTS

Premilitary mental health and somatic symptoms predicted PCS even when adjusting for other variables, yielding an elevated incidence rate ratio (IRR) for posttraumatic stress disorder (PTSD; IRR = 1.23, 95% confidence interval [CI] = 1.06-1.41) and somatic symptoms (mild versus minimal somatic symptoms: IRR = 1.43, 95% CI = 1.31-1.55; moderate/severe versus minimal somatic symptoms: IRR = 1.69, 95% CI = 1.43-2.06), but not for depressive symptoms. When postdeployment mental health and somatic symptom measures were added to the model, the effect of premilitary somatic symptoms remained significant.

CONCLUSIONS

Findings point to potential etiological contributions of premilitary characteristics, particularly a tendency to experience somatic symptoms and PTSD, as well as mTBI and combat experiences, to the development of PCS. PCS were also strongly related to concurrent postdeployment mental health.

Delayed and disorganised brain activation detected with magnetoencephalography after mild traumatic brain injury

BACKGROUND

Awareness to neurocognitive issues after mild traumatic brain injury (mTBI) is increasing, but currently no imaging markers are available for mTBI. Advanced structural imaging recently showed microstructural tissue changes and axonal injury, mild but likely sufficient to lead to functional deficits. Magnetoencephalography (MEG) has high temporal and spatial resolution, combining structural and electrophysiological information, and can be used to examine brain activation patterns of regions involved with specific tasks.

METHODS

16 adults with mTBI and 16 matched controls were submitted to neuropsychological testing (Wechsler Abbreviated Scale of Intelligence (WASI); Conners; Alcohol Use Disorders Identification Test (AUDIT); Generalised Anxiety Disorder Seven-item Scale (GAD-7); Patient Health Questionnaire (PHQ-9); Symptom Checklist and Symptom Severity Score (SCAT2)) and MEG while tested for mental flexibility (Intra-Extra Dimensional set-shifting tasks). Three-dimensional maps were generated using synthetic aperture magnetometry beamforming analyses to identify differences in regional activation and activation times. Reaction times and accuracy between groups were compared using 2×2 mixed analysis of variance.

FINDINGS

While accuracy was similar, patients with mTBI reaction time was delayed and sequence of activation of brain regions disorganised, with involvement of extra regions such as the occipital lobes, not used by controls. Examination of activation time showed significant delays in the right insula and left posterior parietal cortex in patients with mTBI.

CONCLUSIONS

Patients with mTBI showed significant delays in the activation of important areas involved in executive function. Also, more regions of the brain are involved in an apparent compensatory effort. Our study suggests that MEG can detect subtle neural changes associated with cognitive dysfunction and thus, may eventually be useful for capturing and tracking the onset and course of cognitive symptoms associated with mTBI.

Postconcussion Syndrome / Disorder or Mild Traumatic Brain Injury: diagnostic issues and treatment

Traumatic brain injury at the milder end of the spectrum is far more common than the moderate-severe spectrum. Mild traumatic injury (mTBI) accounts for approximately 80% of traumatic brain injuries [1]. Traumatic brain injuries at the milder end of the spectrum which lead to persisting difficulties have been referred to as postconcussion syndrome / postconcussion disorder [2,3]. Individuals with persistent difficulties following a traumatic brain injury at the milder end of the spectrum may be assessed and treated by Neurology, Neuropsychology, and Neuropsychiatry. There has been ongoing research looking at outcomes following traumatic brain injury at the milder end of the spectrum, the validity of postconcussion syndrome/disorder, and treatment of symptoms following milder traumatic brain injuries. This paper will review some of the research in these important areas within neurorehabilitation.

Post-traumatic headaches in civilians and military personnel: a comparative, clinical review

Post-traumatic headache (PTH) is the most frequent symptom after traumatic brain injury (TBI). We review the epidemiology and characterization of PTH in military and civilian settings. PTH appears to be more likely to develop following mild TBI (concussion) compared with moderate or severe TBI. PTH often clinically resembles primary headache disorders, usually migraine. For migraine-like PTH, individuals who had the most severe headache pain had the highest headache frequencies. Based on studies to date in both civilian and military settings, we recommend changes to the current definition of PTH. Anxiety disorders such as post-traumatic stress disorder (PTSD) are frequently associated with TBI, especially in military populations and in combat settings. PTSD can complicate treatment of PTH as a comorbid condition of post-concussion syndrome. PTH should not be treated as an isolated condition. Comorbid conditions such as PTSD and sleep disturbances also need to be treated. Double-blind placebo-controlled trials in PTH population are necessary to see whether similar phenotypes in the primary headache disorders and PTH will respond similarly to treatment. Until blinded treatment trials are completed, we suggest that, when possible, PTH be treated as one would treat the primary headache disorder(s) that the PTH most closely resembles.

Symptomatology and functional outcome in mild traumatic brain injury: results from the prospective TRACK-TBI study

Mild Traumatic Brain Injury (mTBI), or concussion, is a major public health concern. There is controversy in the literature regarding the true incidence of postconcussion syndrome (PCS), with the constellation of physical, cognitive, emotional, and sleep symptoms after mTBI. In the current study, we report on the incidence and evolution of PCS symptoms and patient outcomes after mTBI at 3, 6, and 12 months in a large, prospective cohort of mTBI patients. Participants were identified as part of the prospective, multi-center Transforming Research and Clinical Knowledge in Traumatic Brain Injury Study. The study population was mTBI patients (Glasgow Coma Scale score of 13-15) presenting to the emergency department, including patients with a negative head computed tomography discharged to home without admission to hospital; 375 mTBI subjects were included in the analysis. At both 6 and 12 months after mTBI, 82% (n=250 of 305 and n=163 of 199, respectively) of patients reported at least one PCS symptom. Further, 44.5 and 40.3% of patients had significantly reduced Satisfaction With Life scores at 6 and 12 months, respectively. At 3 months after injury, 33% of the mTBI subjects were functionally impaired (Glasgow Outcome Scale-Extended score ≤6); 22.4% of the mTBI subjects available for follow-up were still below full functional status at 1 year after injury. The term "mild" continues to be a misnomer for this patient population and underscores the critical need for evolving classification strategies for TBI for targeted therapy.

Neuropsychological functioning of combat veterans with posttraumatic stress disorder and mild traumatic brain injury

This study examined the neuropsychological performance of 125 outpatient Operation Enduring Freedom/Operation Iraqi Freedom combat veterans with posttraumatic stress disorder (PTSD) and nonacute mild traumatic brain injury (TBI) (n = 66) and PTSD (n = 59) across multiple cognitive domains to determine whether mild TBI results in greater impairment among those with PTSD. Profile analyses revealed that veterans with PTSD and mild TBI did not differ significantly from those with just PTSD across domains, suggesting that comorbid mild TBI does not result in an additive effect. A norms-based comparison also revealed that neither group demonstrated impaired performance on any of the objective neuropsychological measures examined. However, both groups endorsed moderately elevated symptoms of depression and anxiety, indicating that comorbid psychopathology may contribute to subjective cognitive complaints.