Recovery After Mild Traumatic Brain Injury in Patients Presenting to US Level I Trauma Centers: A Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) Study

Association of Subacute Mild Traumatic Brain Injury Symptoms With Long-Term Persistent Symptoms, Functional Limitations, and Quality of Life

BACKGROUND AND OBJECTIVES

The objective was to evaluate the association of subacute postconcussion symptoms (with the total Rivermead Post-Concussion Questionnaire [RPQ] score) with persistent symptoms, functional limitations, and quality of life at 6 months in patients with mild traumatic brain injury (mTBI).

METHODS

This was a secondary analysis of the Transforming Research and Clinical Knowledge of Traumatic Brain Injury, which was a prospective cohort study of patients with TBI and admission Glasgow Coma Scale score between 13 and 15 at 18 US Level 1 trauma centers through 2014-2018. Participants were included in the study if presenting within 24 hours of external force trauma to the head and met the American Congress of Rehabilitation Medicine's criteria for TBI. Participants completed the RPQ, Glasgow Outcome Scale-Extended (GOSE), and Quality of Life after Brain Injury Overall Scale (QOLIBRI-OS). Primary outcomes were persistent symptoms (≥3 individual RPQ symptoms higher than preinjury level), incomplete recovery (GOSE score <8), and lower quality of life (QOLIBRI-OS score ≤51) at 6 months. Multivariable regression models were developed including RPQ clinical cutoffs at 2 weeks and 3 months and risk factors. Adjusted odds ratios (aORs) and 95% CI are reported for multivariable models. Receiver operating characteristic curves were built to identify discriminative ability of the cutoffs with area under the curve (AUC).

RESULTS

The age of the study cohort (n = 2,000) was 41.1 ± 17.3 years; 33% were female (n = 669), 67% male, 57% White (n = 1,141), and 20% Hispanic (n = 408). RPQ total score ≥14 was associated with higher odds of persistent symptoms (aOR 7.25, 95% CI 5.51-9.54), incomplete recovery (aOR 4.85, 95% CI 3.69-6.39), and lower quality of life (aOR 5.31, 95% CI 3.82-7.40) at 6 months compared with patients below the cutoff. AUC for RPQ total score ≥14 at 2 weeks was 0.76-0.81 across outcomes. RPQ total score ≥12 at 3 months was associated with higher odds of persistent symptoms (aOR 18.22, 95% CI 13.09-25.35), incomplete recovery (aOR 8.44, 95% CI 6.18-11.51), and lower quality of life (aOR 7.45, 95% CI 5.40-10.26) at 6 months compared with patients below the cutoff, with AUCs of 0.80-0.88 across outcomes.

DISCUSSION

Clinical cutoffs for a commonly used TBI symptom questionnaire had acceptable-to-excellent discrimination for 6-month outcomes and can be used by clinicians at 2 weeks after injury to identify patients at risk of chronic impairments and refer for targeted rehabilitation.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that overall TBI symptoms at 2 weeks are predictive of 6-month clinical outcomes.

Long-Term Participation after Mild Traumatic Brain Injury in Comparison to Orthopedic Trauma Controls: Results from a Longitudinal Multicenter Observational Cohort Study

A subgroup of patients shows incomplete recovery after mild traumatic brain injury (mTBI). Outcomes are commonly measured on the level of symptoms or functional recovery. An alternative way to study outcome after mTBI is to measure the level of participation. The objectives of this study were to examine (1) the level of participation in patients with mTBI at 12 months post-injury in comparison to a non-head injury orthopedic trauma control group; (2) the relationship between the outcome domains participation, functional outcome, and post-concussion symptoms. A prospective, longitudinal, multicenter cohort study was conducted. Participants were 140 adults with mTBI and 144 adults with minor (non-head) orthopedic injury. The following outcomes were measured: participation (Utrecht Scale for Evaluation and Rehabilitation-Participation: USER-P), functional outcome (Glasgow Outcome Scale Extended: (GOS-E), and post-concussion symptoms (Rivermead Post-Concussion Symptoms Questionnaire: RPQ). Adults with mTBI have a significantly lower objective participation level (USER-P Frequency scale) than controls. No differences were found between the groups on subjective participation (USER-P Restrictions and Satisfaction scales) nor on functional outcome (GOS-E). Fifty-three people with mTBI (38%) had a score of ≥2 on ≥3 items, while 26 (19%) had an unfavorable USER-P outcome (≥2 restrictions) and only 9 (6.5%) had an unfavorable GOS-E score (<7). In both groups, the presence of persistent symptoms led to a significantly unfavorable outcome on both the USER-P and GOS-E. Participation frequency is lower in mTBI than in orthopedic controls, mainly determined by a significantly lower number of hours of (un)paid work, education, and/or household activities. People with mTBI more often report post-concussion symptoms, but functional recovery is not different between the groups. Participation seems to better represent incomplete recovery than functional outcome, but future research should confirm these findings.

Traumatic Brain Injury Diagnostic Interview: Development, Interrater Reliability, and 2-Week Post-Injury Clinical Profiles

Because most traumatic brain injuries (TBIs) do not present with objective indicators (e.g., neuroimaging findings) to confirm the diagnosis, clinicians often rely on self- or observer-reporting of alteration of consciousness (AOC; e.g., loss of consciousness [LOC], amnesia, other signs of altered mental status), and symptoms to make diagnoses. Moreover, there is no universal agreement on signs and symptoms to sufficiently diagnose TBI, which leads to variability and ambiguity in how TBI is diagnosed in clinical and research settings. The lack of standardized procedures for the diagnosis of acute TBI is a major challenge that hampers the ability to evaluate and compare TBI studies and advance the science and treatment of TBI. We present a new semi-structured TBI Diagnostic Interview (TBI-DI), developed for prospective TBI research to collect injury information important to verifying eligibility for the diagnosis of TBI. Specifically, the TBI-DI collects patient (and/or witness) reports of head trauma, AOC (including LOC and amnesia), and TBI-related symptomology. We describe the protocol, interrater reliability of the TBI-DI items to the same audio-recorded interview, and observed injury characteristics for interviews conducted at 2 weeks post-injury. The sample comprised 335 interviews (320 self-reported, 10 informant-reported, and 5 both) collected on individuals with TBI who were prospectively recruited from 4 U.S. level 1 trauma centers from 2019 to 2023. Cohen's kappa was calculated to summarize interrater reliability n = 288 interviews. UpSet plots were created to illustrate the prevalence of distinct profiles of signs of AOC and symptom reporting. Overall, there was a near-perfect agreement between raters for all AOC descriptors (κ = 0.85-0.92) and symptom items (κ ranging from 0.92 to 0.99). We observed diverse profiles of AOC, with 45% manifesting witnessed LOC, post-traumatic amnesia, or other altered mental status. Patients (n = 325) self-reported 256 different combinations of the 14 acute symptoms included in the interview (most commonly experiencing headache, dizziness, fatigue, and difficulty concentrating). The TBI-DI and associated SOP appear well-suited for use in a multicenter prospective study of TBI. Future research should examine the stability of reporting by respondents and the alignment between interview and objective clinical information. The TBI-DI solicits diverse acute diagnostic information that, when combined with clinical information (including confounding factors) and objective injury indicators, may inform more rigorous scientific reporting and evidence-based TBI diagnostic practices.

Follow up rates and patient interest in clinical care after mild traumatic brain injury presenting to a level 1 trauma center: a TRACK-TBI prospective cohort study

Study objective

To evaluate the rates of clinical follow-up and patient interest in clinical follow-up within the first year of traumatic brain injury (TBI) with presenting Glasgow Coma Scale (GCS) score between 13 and 15.

Methods

This is a secondary analysis of a prospective cohort study which enrolled patients with TBI first evaluated at a 1 of 23 level 1 trauma centers (n = 1,916). At 2 weeks and 3 months, the participants were asked "have you seen any healthcare provider for your TBI?" and "if so, did it help?." Participants also completed the Rivermead Post-Concussion Questionnaire (RPQ), Quality of Life after Brain Injury- Overall Scale (QOLIBRI-OS), and Glasgow Outcome Scale Extended for TBI (GOSE-TBI) at 2 weeks, 3-, 6-, and 12-months. Persistent symptoms were defined as 3+ symptoms worse than pre-injury levels. QOLIBRI-OS≤51 was defined as lower quality of life. GOSE<8 was defined as incomplete recovery.

Results

By 2 weeks, 43% of participants had followed up with a clinical provider; cumulative follow-up within the first year was 63%. Overall, 61% of participants interested in clinical follow-up care reported receiving clinical follow-up care. Participants who received follow-up care reported that it helped at an 86% rate. Of those not interested in follow-up care, 42% reported receiving clinical follow-up care and 86% of those receiving care reported that it helped. Approximately 44% of participants who reported "I did not think I need follow-up" at 2 weeks had incomplete recovery (GOSE<8), 40% had persistent symptoms, and 19% had lower quality of life at 12-months post-injury.

Conclusion

Participants not interested in follow-up care had high rates of poor functional recovery, persistent symptoms and lower quality-of-life at 12 months following traumatic brain injury with GCS 13-15. Education and provider emphasis on the importance of clinical follow-up after hospital discharge with TBI need to be enhanced. Prioritizing timely clinical follow-up for adult patients with TBI with GCS 13 to 15 is critical for improving rates of long-term recovery in this population.

Associations Between Brain Metabolites Measured With MR Spectroscopy and Head Impacts in High School American Football Athletes

BACKGROUND

While changes in brain metabolites after injury have been reported, relationships between metabolite changes and head impacts are less characterized.

PURPOSE

To investigate alterations in neurochemistry in high school athletes as a function of head impacts, concussion, and the use of a jugular vein compression (JVC) collar.

STUDY TYPE

Prospective controlled trial.

SUBJECTS

A total of 284 male American football players, divided into JVC collar and noncollar groups; 215 included in final analysis (age = 15.9 ± 1.0 years; 114 in collar group).

FIELD STRENGTH/SEQUENCE

3 Tesla/T1-weighted gradient echo, 1H point resolved spectroscopy, acquired between August and November 2018.

ASSESSMENT

Head impacts were quantified using accelerometers. Concussion was diagnosed by medical professionals for each team. Pre- to postseason differences in total N-acetylaspartate (tNAA), total choline (tCho), myo-inositol (myoI), and glutamate + glutamine (Glx), in primary motor cortex (M1) and anterior cingulate cortex (ACC), relative to total creatine (tCr), were determined.

STATISTICAL TESTS

Group-wise comparisons were performed using Wilcoxon signed-rank, Friedman's, and Mann-Whitney U tests. Relationships between ∆metabolite/tCr and mean g-force were analyzed using linear regressions accounting for concussion and JVC collar. Significance was set at P ≤ 0.05.

RESULTS

In participants without concussion, a significant decrease in tCho/tCr (0.233 ± 1.40 × 10-3 to 0.227 ± 1.47 × 10-7) and increase in Glx/tCr (1.60 ± 8.75 × 10-3 to 1.63 ± 1.08 × 10-2) in ACC were observed pre- to postseason. The relationship between ∆tCho/tCr in M1 and ACC and mean g-force from >80 g to >140 g differed significantly between participants with and without concussion (M1 β ranged from 3.9 × 10-3 to 2.1 × 10-3; ACC β ranged from 2.7 × 10-3 to 2.1 × 10-3). Posthoc analyses revealed increased tCho/tCr in M1 was positively associated with mean g-force >100 g (β = 3.6 × 10-3) and >110 g (β = 2.9 × 10-3) in participants with concussion. Significant associations between ∆ myoI / tCr in ACC and mean g-force >110 g (β = -1.1 × 10-3) and >120 g (β = -1.1 × 10-3) were observed in the collar group only.

DATA CONCLUSION

Diagnosed concussion and the use of a JVC collar result in distinct neurochemical trends after repeated head impacts.

LEVEL OF EVIDENCE

2 TECHNICAL EFFICACY: Stage 3.

Current and prospective roles of magnetic resonance imaging in mild traumatic brain injury

There is unmet clinical need for biomarkers to predict recovery or the development of long-term sequelae of mild traumatic brain injury, a highly prevalent condition causing a constellation of disabling symptoms. A substantial proportion of patients live with long-lasting sequelae affecting their quality of life and ability to work. At present, symptoms can be assessed through clinical tests; however, there are no imaging or laboratory tests fully reflective of pathophysiology routinely used by clinicians to characterize post-concussive symptoms. Magnetic resonance imaging has potential to link subtle pathophysiological alterations to clinical outcomes. Here, we review the state of the art of MRI research in adults with mild traumatic brain injury and provide recommendations to facilitate transition into clinical practice. Studies utilizing MRI can inform on pathophysiology of mild traumatic brain injury. They suggest presence of early cytotoxic and vasogenic oedema. They also show that mild traumatic brain injury results in cellular injury and microbleeds affecting the integrity of myelin and white matter tracts, all processes that appear to induce delayed vascular reactions and functional changes. Crucially, correlates between MRI parameters and post-concussive symptoms are emerging. Clinical sequences such as T1-weighted MRI, susceptibility-weighted MRI or fluid attenuation inversion recovery could be easily implementable in clinical practice, but are not sufficient, in isolation for prognostication. Diffusion sequences have shown promises and, although in need of analysis standardization, are a research priority. Lastly, arterial spin labelling is emerging as a high-utility research as it could become useful to assess delayed neurovascular response and possible long-term symptoms.

Physiological outcomes of physical activity interventions in persistent postconcussive symptoms: a scoping review protocol

There are limited therapeutic options for patients with persistent postconcussive symptoms (PPCSs). Most PPCS assessments focus on subjective measures of progression and symptom monitoring. While early exercise interventions for rehabilitation are now considered best practice for acute concussion, no comprehensive review exists on how physical activity objectively and physiologically affects outcomes in PPCS. This scoping review protocol outlines the methods to identify the efficacy of therapeutic exercise interventions for PPCS, emphasising their impact on physiological parameters, including cardiovascular autonomic responses and cerebral autoregulation. Using the Patient, Intervention, Comparison and Outcome (PICO) framework, we will include all studies presenting original data. Narrative summaries will provide clinicians. An initial search in Medline/EMBASE/PubMed, Cochrane Library, PsycINFO, Web of Science and Scopus will be completed. Key parameters from each study will be extracted, tabulated and discussed in a narrative inquiry. The study references will be reviewed for additional studies meeting the inclusion criteria. Future research applications from the findings will be emphasised. After completion of the review, the results will be stratified by type of physical activity as the intervention, emphasising the physiological outcomes. Mapping these findings will allow us to identify the key research priorities for future studies. Findings will be shared with PPCS practitioners and local/national committees and submitted for conferences and publications.

Beyond Glasgow Coma Scale: Prehospital prediction of traumatic brain injury

INTRODUCTION

Early identification of traumatic brain injury followed by timely, targeted treatment is essential. We aimed to establish the ability of prehospital Glasgow Coma Scale score alone and combined with vital signs to predict hospital-diagnosed traumatic brain injury.

METHODS

This study included adults from the 2017-2020 Trauma Quality Improvement Program data set with blunt mechanism. We calculated test characteristics of prehospital Glasgow Coma Scale score ≤12 alone and Glasgow Coma Scale score combined with heart rate and systolic blood pressure for predicting (1) any traumatic brain injury and (2) moderate to severe traumatic brain injury. Diagnostic performances were calculated in all patients and older adults (≥55 years). We used decision curve analysis to determine the net diagnostic benefit of prehospital Glasgow Coma Scale score combined with heart rate + systolic blood pressure over Glasgow Coma Scale score alone.

RESULTS

Of 1,687,336 patients, 39.1% had any traumatic brain injury, 3.7% had moderate to severe traumatic brain injury, and 9.1% had a prehospital Glasgow Coma Scale score ≤12. Prehospital Glasgow Coma Scale score ≤12 alone had a sensitivity 83.1%, specificity 93.7%, negative predictive value 99.3%, and positive predictive value 33.7% for predicting moderate to severe traumatic brain injury. Adding prehospital heart rate <65/min and systolic blood pressure >150 mm Hg to Glasgow Coma Scale score ≤12 improved the positive predictive value for moderate to severe traumatic brain injury (55.3%), with a preserved negative predictive value of 96.4%. Decision curve analysis showed the traumatic brain injury prediction model including prehospital heart rate and systolic blood pressure had the greatest net benefit across most threshold probabilities.

CONCLUSION

Less than a third of adult blunt trauma patients with a prehospital Glasgow Coma Scale score ≤12 have moderate to severe traumatic brain injury. Supplementing Glasgow Coma Scale score with prehospital vital signs improves diagnostic accuracy, potentially by filtering out patients with altered consciousness due to shock. Future work should better identify patients for traumatic brain injury-specific treatments in prehospital settings, including triage destination.

Outcomes after Traumatic Brain Injury with and Without Computed Tomography

Our recent improved understanding of traumatic brain injury (TBI) comes largely from cohort studies of TBI patients with indication for computed tomography (CT). Using CT head as an inclusion criterion may overestimate poor outcomes after TBI with Glasgow Coma Scale (GCS) 13-15. We aimed to compare outcomes after TBI in adults who had a head CT scan (with negative findings) versus those who had no CT when presenting to an emergency department. This was a secondary analysis of a trial that recruited adults with GCS = 13-15 after TBI in Vancouver, Canada. We included 493 participants (18-69 years, 54% female), after removing n = 19 with traumatic abnormalities on CT (intracranial and/or skull fracture). Outcomes were Glasgow Outcome Scale Extended (GOSE), Rivermead Post-Concussion Symptoms Questionnaire (RPQ), Patient Health Questionnaire (PHQ)-9, and generalized anxiety disorder (GAD)-7 at 6 months post-injury. Over half (55%) of participants received a CT. At 6 months, 55% of participants with CT and 49% without CT had functional limitations on GOSE; 32% with CT and 33% without CT reported severe post-concussion symptoms (RPQ ≥16); 26% (with CT) and 28% (without CT) screened positive for depression (PHQ-9 ≥ 10), and 25% (with CT) and 28% (without CT) screened positive for anxiety (GAD-7 ≥ 8). In regression adjusted for personal variables, participants with CT had somewhat higher odds of worse functioning (ordinal GOSE; 1.4, 95% CI 1.0-2.0) but similar odds of severe post-concussion symptoms (1.1, 95% CI: 0.7-1.7), and depression (1.1, 95% CI: 0.7-1.7) and anxiety (1.0, 95% CI: 0.6-1.5) symptoms. Adults with and without head CT have mostly comparable outcomes from TBI with GCS = 13-15. Requiring CT by clinical indication for study entry may not create problematic selection bias for outcome research.

Identifying Growth Hormone Deficiency in Brain-Injured Patients: The Quality of Life Scale-99

Traumatic brain injury (TBI) is frequently associated with hypopituitarism. The hypothalamic-pituitary axis appears to be susceptible to the same forces that cause injury to the parenchyma of the brain. Following even a mild TBI (mTBI), patients may suffer transient or permanent decreases in anterior pituitary hormones, including somatotropin (growth hormone [GH]), gonadotropins (luteinizing hormone and follicle-stimulating hormone), thyrotropin, and adrenocorticotropic hormone, with the most frequent long-term deficiency being GH deficiency (GHD). GHD is common after mTBI and is often the cause of persistent post-concussive symptoms a year or more post-injury. GHD is known to cause physical and cognitive fatigue, cognitive inefficiency, metabolic changes, and a range of psychological symptoms. Confusing the picture is that some symptoms of GHD are also common to brain injury itself. To facilitate the detection of GHD when comorbid with TBI, we utilized a new symptom inventory, the Quality-of-Life Scale-99 (QoLS-99), and administered it to a cohort of chronic TBI subjects with and without GHD, distinguished using the insulin tolerance test (ITT). Between 2018 and 2023, 371 patients completed the QoLS-99, of which 263 underwent GH testing with the ITT. Of these 263 patients, 136 (52%) were diagnosed with GHD. A retrospective comparison of QoLS-99 scores found that loss of libido (p < 0.006), a reliance on sleep aids (p < 0.011), and feeling overweight (p < 0.015) were the strongest univariate predictors of GHD. Most survey items did not elicit a significant difference in response between the GHD groups, and for those that did, effect sizes were mild to moderate. Still, initial findings demonstrate strong predictive value in a subset of survey items (i.e., GHD symptoms) that are most discriminating in the sample of patients with TBI. A multivariate prediction model using this subset of questions was able to differentiate GHD status in patients with TBI, correctly identifying 88% of GHD cases with a 37% false positive rate. Based on these findings, we recommend that clinicians inquire about libido, insomnia, and body image as potential markers for GHD. Furthermore, given the amenability of patients with GHD to growth hormone replacement therapy, we strongly encourage clinicians and basic scientists to develop interventions for the large and underserved population of patients with TBI with comorbid GHD.

Four-Year Trajectories of Symptoms and Quality of Life in Individuals Hospitalized After Mild Traumatic Brain Injury

OBJECTIVES

To (1) detect distinct trajectories of symptoms and quality of life (QoL) over the first 4 years after mild traumatic brain injury (mTBI); (2) assess the relationship between symptom trajectory membership and QoL trajectory membership; and (3) identify participant characteristics associated with QoL trajectory membership.

DESIGN

Prospective longitudinal cohort study. Assessments occurred at 4, 8, 12, 24, 36, and 48 months after mTBI.

SETTING

Recruitment occurred in Level 1 Trauma Centers; follow-up was completed in the community.

PARTICIPANTS

Participants were 143 adults (aged 18-65y) who sustained an mTBI and were hospitalized (≥24h) at a Level 1 Trauma Center.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Fatigue Severity Scale, Hospital Anxiety and Depression Scale, Insomnia Severity Index, Medical Outcomes Study Cognitive Functioning Scale, Quality of Life after Brain Injury questionnaire, presence/absence of headaches or dizziness.

RESULTS

Group-based trajectory modeling revealed relatively stable symptom and QoL trajectories over time. Considerable percentages of participants were classified in trajectories of clinically significant symptoms throughout the full follow-up period: 62% for subjective cognitive issues, 54% for fatigue, 44% for anxiety, 43% for insomnia, 27% for depression, 23% for headaches, and 17% for dizziness. Sixty-six percent of participants belonged to trajectories of persistently poor QoL. For all symptoms, trajectories of greater severity were associated with trajectories of poorer QoL. None of the sociodemographic or injury-related variables examined were associated with QoL trajectory membership.

CONCLUSIONS

A substantial proportion of individuals hospitalized after mTBI experiences clinically significant persistent symptoms ≤4 years after injury, and those with more severe symptoms have poorer QoL. Further research is required to better understand the factors leading to symptom persistence and poor QoL.

Critical Review of Recently Published Studies Claiming Long-Term Neurocognitive Abnormalities in Mild Traumatic Brain Injury

Mild traumatic brain injury (mTBI) is the most common claimed personal injury condition for which neuropsychologists are retained as forensic experts in litigation. Therefore, it is critical that experts have accurate information when testifying as to neurocognitive outcome from concussion. Systematic reviews and six meta-analyses from 1997 to 2011 regarding objective neurocognitive outcome from mTBI provide no evidence that concussed individuals do not return to baseline by weeks to months post-injury. In the current manuscript, a critical review was conducted of 21 research studies published since the last meta-analysis in 2011 that have claimed to demonstrate long-term (i.e., ≥12 months post-injury) neurocognitive abnormalities in adults with mTBI. Using seven proposed methodological criteria for research investigating neurocognitive outcome from mTBI, no studies were found to be scientifically adequate. In particular, more than 50% of the 21 studies reporting cognitive dysfunction did not appropriately diagnose mTBI, employ prospective research designs, use standard neuropsychological tests, include appropriate control groups, provide information on motive to feign or use PVTs, or exclude, or adequately consider the impact of, comorbid conditions known to impact neurocognitive scores. We additionally analyzed 15 studies published during the same period that documented no longer term mTBI-related cognitive abnormalities, and demonstrate that they were generally more methodologically robust than the studies purporting to document cognitive dysfunction. The original meta-analytic conclusions remain the most empirically-sound evidence informing our current understanding of favorable outcomes following mTBI.

Acceptance and commitment therapy for mild traumatic brain injury (ACTion-mTBI): a quasiexperimental feasibility study

OBJECTIVES

This study aimed to determine the feasibility of recruiting, implementing and delivering an acceptance and commitment therapy (ACT) intervention for mild traumatic brain injury (mTBI) (ACTion-mTBI) within a multidisciplinary outpatient mTBI rehabilitation services. The study also aimed to conduct a preliminary investigation of group differences between ACTion-mTBI and an equivalent cognitive behavioural therapy (CBT) intervention on various outcome measures and psychological treatment targets.

DESIGN

A two-arm quasiexperimental feasibility study.

SETTING

Five mTBI rehabilitation clinics throughout New Zealand.

INTERVENTION

Psychologists working in mTBI rehabilitation clinics throughout New Zealand were trained to deliver ACTion-mTBI or CBT. Eligible participants were assigned to either of these interventions based on the psychologist available at the clinic they were referred to. ACTion-mTBI is a five sessions intervention that incorporates all six components of the ACT model. The CBT intervention is an equivalent intervention and incorporating all four components of the CBT model. Both interventions are adapted for an mTBI context.

PRIMARY OUTCOME MEASURES

The primary outcomes were related to the feasibility of ACTion-mTBI. This included recruitment, retention and treatment adherence of participants, study procedure and fidelity of treatment delivery.

SECONDARY OUTCOME MEASURES

To explore group differences between ACTion-mTBI and CBT on functional disability, postconcussion symptoms, mental health, valued living and psychological flexibility.

RESULTS

The intervention proved feasible to implement with community-based mTBI rehabilitation services. Attrition rates were comparable between the two psychological interventions and fidelity to the treatments was high. At post-treatment, when covarying pretreatment scores, ACTion-mTBI had a significantly greater improvement in functional disability than CBT (moderate effect). ACTion-mTBI also had a significantly greater reduction in postconcussion symptoms, anxiety and stress. Promisingly, significant improvements in psychological flexibility was also found post-treatment. There were no group differences on depressive symptoms and valued living.

CONCLUSION

We conclude that a full clinical trial of ACTion-mTBI for individuals with mTBI is feasible and warranted.

TRIAL REGISTRATION NUMBER

ACTRN1262100059482.

Guiding Oligodendrocyte Progenitor Cell Maturation Using Electrospun Fiber Cues in a 3D Hyaluronic Acid Hydrogel Culture System

The current lack of therapeutic approaches to demyelinating disorders and injuries stems from a lack of knowledge surrounding the underlying mechanisms of myelination. This knowledge gap motivates the development of effective models to study the role of environmental cues in oligodendrocyte progenitor cell (OPC) maturation. Such models should focus on determining, which factors influence OPCs to proliferate and differentiate into mature myelinating oligodendrocytes (OLs). Here, we introduce a hyaluronic acid (HA) hydrogel system composed of cross-linked HA containing encapsulated HA fibers with swollen diameters similar to mature axons (2.7 ± 0.2 μm). We tuned hydrogel storage moduli to simulate native brain tissue (200-2000 Pa) and studied the effects of fiber presence on OPC proliferation, metabolic activity, protein deposition, and morphological changes in gels of intermediate storage modulus (800 ± 0.3 Pa). OPCs in fiber-containing gels at culture days 4 and 7 exhibited a significantly greater number of process extensions, a morphological change associated with differentiation. By contrast, OPCs in fiber-free control gels maintained more proliferative phenotypes with 2.2-fold higher proliferation at culture day 7 and 1.8-fold higher metabolic activity at culture days 4 and 7. Fibers were also found to influence extracellular matrix (ECM) deposition and distribution, with more, and more distributed, nascent ECM deposition occurring in the fiber-containing gels. Overall, these data indicate that inclusion of appropriately sized HA fibers provides topographical cues, which guide OPCs toward differentiation. This HA hydrogel/fiber system is a promising in vitro scheme, providing valuable insight into the underlying mechanisms of differentiation and myelination.

In People With Subacute Mild Traumatic Brain Injury, Earlier Physical Therapy Improved Symptoms at a Faster Rate Than Later Physical Therapy: Randomized Controlled Trial

IMPORTANCE

There is unclear evidence on when to initiate physical therapy after mild traumatic brain injury (mTBI) in a non-athlete, adult population.

OBJECTIVE

The objective of this study was to investigate physical therapy timing after mTBI through changes in patient-reported and clinically-assessed tools and objective and mechanism measurements of sensorimotor balance control.

DESIGN

This study was an investigator-blinded randomized control trial (NCT03479541).

SETTING

The study took place at an academic research center.

PARTICIPANTS

Two hundred and three participants were randomized to earlier physical therapy (n = 82) or to later physical therapy (n = 121).

INTERVENTION

After enrollment, the earlier physical therapy group started rehabilitation within 1 week and the later group started rehabilitation after a 6-week wait period. All participants received similar rehabilitation; 6-week program administered and progressed by licensed physical therapists.

MAIN OUTCOMES AND MEASURES

The primary outcome was the Dizziness Handicap Inventory (DHI). Secondary outcomes included common patient-reported/clinical assessments of mTBI and objective/mechanism measurements of balance, including novel measures of central sensorimotor integration. Differences between and within the groups on outcomes were examined with linear mixed-effect models, t tests, and effect sizes.

RESULTS

While both groups significantly improved and reached similar levels on patient-reported outcomes (DHI and secondary outcomes), the earlier physical therapy group had significantly larger and faster rates of improvement compared to later physical therapy. There were differential effects of physical therapy timing on the objective/mechanism-measured outcomes. Specifically, there were significant improvements in sensorimotor time delay for the earlier physical therapy group and no change in the later group. Further, the later group worsened in the motor activation components for balance control while there was no change in the early group.

CONCLUSION AND RELEVANCE

Earlier physical therapy after mTBI can improve symptoms at a faster rate relative to later physical therapy. Earlier physical therapy also showed improvements in sensorimotor aspects of balance control, not seen in the later group. There may be an important window to address central sensorimotor deficits after mTBI.

On-TRACC Pilot Study: A Novel Intervention for Persistent Post-Concussive Cognitive Symptoms

OBJECTIVE

To present the results of a pilot study of On-TRACC (Tools for Recovery and Clinical Care), a novel intervention for individuals experiencing persistent cognitive difficulties after mild traumatic brain injury (mTBI). On-TRACC is a 5-session, 1:1 manualized treatment that integrates psychoeducation, cognitive rehabilitation strategies, and self-management skills to target symptoms and increase understanding of the interaction between cognitive difficulties, injury history, and comorbid medical and psychological conditions. The primary study goals were to evaluate the feasibility, acceptability, and preliminary effectiveness of On-TRACC.

SETTING

Veterans Affairs medical center and an academic medical center.

PARTICIPANTS

Veterans and civilian adults (n = 28) >3 months post-mTBI with current self-reported cognitive difficulties.

DESIGN

In this single-group, open-label pilot study, all participants received On-TRACC (5 sessions) via video-based telehealth.

MAIN MEASURES

Primary measures were feasibility (eg, session attendance and homework completion rate, dropout rate, and treatment fidelity) and acceptability (treatment satisfaction/helpfulness ratings). Preliminary effectiveness was explored by measuring pre- to post-intervention change in cognitive symptom level and attribution, perceived self-efficacy, use of compensatory strategies, daily functioning, quality of life, and planned future engagement in health care.

RESULTS

The On-TRACC completion rate for all enrolled participants was 79% (with 88% treatment completion rate for participants who started On-TRACC); homework was fully or partially completed for 98% of attended sessions. Treatment satisfaction ratings were high, with 95% satisfied with the information and skills learned. There were no adverse events. Positive pre- to posttreatment changes were seen in cognitive self-efficacy, symptom attribution, functional status, quality of life, and planned engagement in care for comorbid conditions.

CONCLUSION

On-TRACC was a feasible and acceptable intervention for individuals with chronic cognitive difficulties following mTBI. Additional research, including a randomized clinical trial, is needed to evaluate the efficacy of this intervention and its long-term impact on outcomes in this clinical population.

Testing an Electronic Patient-Reported Outcome Platform in the Context of Traumatic Brain Injury: PRiORiTy Usability Study

Background

Traumatic brain injury (TBI) is a significant public health issue and a leading cause of death and disability globally. Advances in clinical care have improved survival rates, leading to a growing population living with long-term effects of TBI, which can impact physical, cognitive, and emotional health. These effects often require continuous management and individualized care. Traditional paper-based assessments can be cumbersome, potentially impeding regular monitoring of patient-reported outcomes (PROs). Electronic PROs (ePROs) offer a promising alternative by enabling real-time symptom tracking, which can facilitate early identification of issues, support shared decision-making, and improve outcomes for patients with TBI.

Objective

This study evaluates the usability of an ePRO platform-Atom5-for individuals with TBI. By analyzing how patients use the system to report their symptoms, the study aims to identify usability issues, assess user satisfaction, and determine the potential of Atom5 to support ongoing patient-centered care.

Methods

Atom5 was customized to enable individuals with TBI to report their symptoms. Usability testing was conducted through one-on-one sessions with participants recruited from Headway UK-an organization supporting brain injury survivors. Each participant took part in cognitive interviews using with the "Think Aloud" method, encouraging them to verbalize their thoughts and experiences while using the platform. This approach provided qualitative insights into areas of difficulty, usability strengths, and accessibility barriers. User satisfaction was quantitatively assessed with a brief 4-item questionnaire based on the System Usability Scale. Usability outcomes were analyzed for critical and noncritical errors, focusing on user experience and overall satisfaction.

Results

In total, 9 participants completed a single usability testing session using Atom5, including 4 men, 4 women, and 1 nonbinary individual; 4 participants were under 55 years old, and 6 had their TBI <10 years ago. Finally, 8 participants used an Android device. The platform included measures for anxiety (Generalized Anxiety Disorder-2 item), depression (Patient Health Questionnaire-2), posttraumatic stress disorder (Posttraumatic Stress Disorder checklist 2), and TBI-specific quality of life (Traumatic Brain Injury - Quality of Life Short form) and a total of 26 questions. Overall, all participants were satisfied with the system, noting that it was easy to navigate and accessible despite difficulties in understanding some questions. Further, 6 participants encountered no errors, while 1 participant reported one critical error and 2 others reported one noncritical error each. The participants rated their overall satisfaction with the platform at an average score of 3.9 (SD 0.49) out of 5.

Conclusions

This usability study suggests that individuals living with TBI can effectively report symptoms using the Atom5 ePRO platform, with generally high satisfaction and few usability issues, thereby enabling continuous monitoring and proactive symptom management. Future ePRO development should focus on inclusivity and adaptability to address the diverse needs of patients with TBI, ensuring these tools can effectively support a wide range of users.

Mild TBI Changes Brain and Plasma Neurosteroid Levels in Mice

Mild traumatic brain injury (mTBI) accounts for 80% of all TBI, may be associated with chronic impairments, and is difficult to diagnose due to a lack of objective markers. In this study, we investigated whether neurosteroids can serve as blood biomarkers for mTBI. Two cohorts of C57BL/6 mice were subjected to a model of mTBI combining impact with rotational acceleration or sham surgery. The first cohort underwent neurological testing for anxiety, balance, and locomotion before and after mTBI. For the second cohort, brains and plasma were collected 6 or 24 h after mTBI to measure steroid and neurosteroid levels by gas chromatography-tandem mass spectrometry. Traumatized mice exhibited significantly prolonged wake-up time from anesthesia, transiently increased beam-walk time, and mild astrogliosis compared with their control counterparts, but did not suffer from skull fractures, intracranial hemorrhage, or mortality. Isopregnanolone and 3β,5α-tetrahydrodeoxycorticosterone (ISODOC) were significantly decreased by more than 50% in brain parenchyma at 6 and 24 h after mTBI, while ISODOC was also significantly decreased in plasma (-75%). Therefore, ISODOC may be a candidate diagnostic biomarker for mTBI.

Association of Blood-Based Biomarkers and 6-Month Patient-Reported Outcomes in Patients With Mild TBI: A CENTER-TBI Analysis

BACKGROUND AND OBJECTIVES

There is seemingly contradictory evidence concerning relationships between day-of-injury biomarkers and outcomes after mild traumatic brain injury (mTBI). To address this issue, we examined the association between a panel of biomarkers and multidimensional TBI outcomes.

METHODS

Participants with mTBI (Glasgow coma scores [GCSs] 13-15) were selected from Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury, a European observational study recruiting patients with TBI with indication for brain CT and presentation within 24 hours. Exclusion criteria for this secondary analysis were age younger than 16 years, incomplete biomarker panel, death, or no recorded outcomes. Participants were separated into 2 groups, CT-negative and CT-positive. Multivariable binary logistic regression was used to assess the relation between the log biomarker level (glial fibrillary acidic protein [GFAP], neurofilament light [NfL], neuron-specific enolase [NSE], S100 calcium-binding protein B [S100B], tau, ubiquitin C-terminal hydrolase L1 [UCH-L1]) and dichotomized 6-month outcomes (functional outcomes [GOSE score <8], health-related quality of life [HRQoL; Quality of Life after Brain Injury-Overall Scale (QOLIBRI-OS) score <52, Short-Form 12-Item Survey version 2 Mental Component Summary (SF12v2 MCS) score <40, Short-Form 12-Item Survey version 2 Physical Component Summary (SF12v2 PCS) score <40], persistent postconcussion symptoms [Rivermead Post-Concussion Symptoms Questionnaire score ≥16], anxiety disorder [Generalized Anxiety Disorder-7 (GAD-7) score ≥8], depression [Patient Health Questionnaire-9 (PHQ-9) score ≥10], and post-traumatic stress disorder [PTSD Checklist for DSM-5 (PCL-5) score ≥33]).

RESULTS

A total of 1,589 participants (865 CT-negative, 724 CT-positive) were included (77% GCS 15, median age 52 years, 66% male). Higher biomarker levels were associated with a GOSE score <8: CT-negative: S100B (odds ratio [OR] 1.78, 95% CI 1.43-2.23) and UCH-L1 (OR 1.16, 95% CI 1.01-1.33); CT-positive: GFAP (OR 1.22, 95% CI 1.11-1.36), NfL (OR 1.30, 95% CI 1.11-1.52), S100B (OR 1.51, 95% CI 1.23-1.86), tau (OR 1.36, 95% CI 1.17-1.59), and UCH-L1 (OR 1.34, 95% CI 1.17-1.53). In CT-positive participants, positive association was seen between NfL (OR 1.3, 95% CI 1.06-1.60) and UCH-L1 (OR 1.28, 95% CI 1.07-1.54) with QOLIBRI-OS; S100B (OR 1.32, 95% CI 1.02-1.70) with SF12v2 PCS; and NSE (OR 1.52, 95% CI 1.06-2.18) and UCH-L1 (OR 1.21, 95% CI 1.01-1.46) with the GAD-7. However, in CT-negative participants only, negative associations were seen between GFAP and impairment on the QOLIBRI-OS (OR 0.76, 95% CI 0.66-0.88), SF12v2 MCS (OR 0.71, 95% CI 0.61-0.82), SF12v2 PCS (OR 0.79, 95% CI 0.68-0.91), GAD-7 (OR 0.80, 0.68-0.95), PHQ-9 (OR 0.80, 95% CI 0.68-0.93), and PCL-5 (OR 0.80, 95% CI 0.66-0.97).

DISCUSSION

Participants with higher biomarker levels had greater odds of impaired functional recovery. However, in CT-negative participants, higher GFAP concentrations were associated with better HRQoL and less impaired mental health. Further exploration is required of the patient phenotypes that may explain the relationships observed in this analysis.

Diagnosis and Management of Mild Traumatic Brain Injury (mTBI): A Comprehensive, Patient-centered Approach

PURPOSE OF REVIEW

The purpose of this review is to provide an update regarding recent research and recommendations in the care of mild traumatic brain injury (mTBI).

RECENT FINDINGS

New diagnostic criteria for mTBI have recently been developed by the American Congress of Rehabilitation Medicine through the Delphi method and this will help to standardize assessment, diagnosis, and treatment. Symptoms of mTBI are diverse and can sometimes become persistent. Treatment of mTBI should be patient-centered and may require subspeciality referral and coordinated, inter-disciplinary, or multi-disciplinary treatment.

Peritraumatic Context and Long-Term Outcomes of Concussion

Importance

There has been a great deal of interest in mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD) and their association with one another, yet their interaction and subsequent associations with long-term outcomes remain poorly understood.

Objective

To compare the long-term outcomes of mTBI that occurred in the context of psychological trauma (peritraumatic context) with mTBI that did not (nonperitraumatic context).

Design, Setting, and Participants

This cohort study of post-9/11 US veterans used data from the Translational Research Center for Traumatic Brain Injury and Stress Disorders (TRACTS) study at the Veterans Affairs Boston Healthcare System, which began in 2009; the current study utilized data from baseline TRACTS visits conducted between 2009 and 2024. Data analysis occurred from January to October 2024.

Exposures

Peritraumatic mTBI, nonperitraumatic mTBI, or no TBI.

Main Outcomes and Measures

The primary outcomes were PTSD severity (measured by the Clinician-Administered PTSD Scale-4th edition), postconcussive symptoms (measured by the Neurobehavioral Symptom Inventory), and self-reported disability status (measured by the World Health Organization Disability Assessment Schedule II). Differences between groups were compared using analyses of covariance with least significant difference comparisons.

Results

This sample of 567 post-9/11 veterans (mean [SD] age, 33.72 [9.29] years; 507 men [89.4%]; mean [SD] years of education, 14.19 [2.16]) included 183 individuals with no TBI, 189 individuals with nonperitraumatic mTBI, and 195 individuals with peritraumatic mTBI. Veterans with a history of peritraumatic mTBI had greater PTSD severity (F2,552 = 8.45; P < .001), postconcussive symptoms (F2,533 = 11.09; P < .001), and disability (F2,527 = 11.13; P < .001) than the nonperitraumatic mTBI and no TBI groups. Importantly, no significant differences in any outcome measure between nonperitraumatic mTBI and no TBI groups were observed.

Conclusions and Relevance

This cohort study found that mTBI was only associated with long-term consequences when it co-occurred with a traumatic event exposure. This finding raises a novel hypothesis of the association of mTBI with PTSD, in which the acute biological and physiological outcomes of mTBI may be associated with temporarily scaffolding the formation of PTSD symptoms, which could enhance the production of long-term postconcussive symptoms and disability.

Cognitive performance and perceived injury symptoms in school-aged children and adolescents after mild traumatic brain injury. A long-term follow-up study

BACKGROUND

Mild traumatic brain injuries (mTBIs) are common in childhood and adolescence, but their long-term effects remain poorly understood.

OBJECTIVE

Examine cognitive performances and perceived injury symptoms, on average, six years after an mTBI in school-aged children and adolescents, and to evaluate longitudinal changes in performance and symptoms during the follow-up period.

MATERIALS AND METHOD

Finnish children aged 7-15 years who were cared for mTBI at Turku University Hospital during 2010-2016, with brain imaging and neuropsychological assessment linked to the event available, were identified and targeted for follow-up assessment. We gathered cognitive performance and injury symptom data, as recorded at 1-3 months post-injury, retrospectively from the hospital patient records. Age-appropriate versions of Wechsler Intelligence Scale, Conners Continuous Performance Test II, PedsQL™ Multidimensional Fatigue Scale and semi-structured interview of symptoms were used as outcome measures at follow-up.

RESULTS

Age-adjusted verbal performance scores of the participants deteriorated during follow-up, and were predicted by younger age at injury, male sex, and lower verbal performance scores at the original assessment. At follow-up 64.9 % reported one or more injury symptoms, with 48.6 % of those displaying symptoms at the original assessment continuing to report symptoms at follow-up. The most persistent injury symptoms were verbal difficulties, headache and fatigue.

CONCLUSIONS

The results stress the importance of identifying and monitoring children recovering slowly after a hospital-treated mTBI, as they might be at increased risk for long-lasting problems.

Using artificial intelligence to optimize anti-seizure treatment and EEG-guided decisions in severe brain injury

Electroencephalography (EEG) is invaluable in the management of acute neurological emergencies. Characteristic EEG changes have been identified in diverse neurologic conditions including stroke, trauma, and anoxia, and the increased utilization of continuous EEG (cEEG) has identified potentially harmful activity even in patients without overt clinical signs or neurologic diagnoses. Manual annotation by expert neurophysiologists is a major resource limitation in investigating the prognostic and therapeutic implications of these EEG patterns and in expanding EEG use to a broader set of patients who are likely to benefit. Artificial intelligence (AI) has already demonstrated clinical success in guiding cEEG allocation for patients at risk for seizures, and its potential uses in neurocritical care are expanding alongside improvements in AI itself. We review both current clinical uses of AI for EEG-guided management as well as ongoing research directions in automated seizure and ischemia detection, neurologic prognostication, and guidance of medical and surgical treatment.

Examining acquired brain injury-associated symptoms and fluid-based biomarkers in females surviving intimate partner violence: An observational pilot study protocol

BACKGROUND

Acquired brain injury (ABI), including traumatic brain injury and hypoxic/anoxic injury, presents significant public health concerns; however, existing literature has focused primarily on male populations, such as military personnel and contact sports participants. Sex-related differences in ABI outcomes necessitate focused research due to potential heightened risk and distinct physiological responses among females.

OBJECTIVES

This pilot study aims to explore fluid-based biomarkers for neurological injury and inflammation in females experiencing intimate partner violence (IPV)-related assaults to the head, neck, or face. It seeks to assess the feasibility and acceptability of non-invasive sweat patch collection for biomarker analysis and its association with post-injury symptoms.

DESIGN

This study will be a prospective longitudinal observational pilot study involving approximately 50 participants recruited from two mid-Atlantic-based hospital emergency departments.

METHODS AND ANALYSIS

Participants will undergo clinical interviews, provide blood and sweat samples, and complete questionnaires assessing ABI history, IPV-related symptoms, cognitive function, psychological well-being, and sweat patch acceptability, across three study visits. Screening procedures will identify eligible participants, followed by consent procedures, biosample collection, brain injury and IPV history survey administration, symptom and cognitive function instrument administration, and acute medical record data collection. Analyses will include random effects regression, product moment correlations, and descriptive statistics.

ETHICS

Participants will be informed about the study's purpose, procedures, and potential risks before providing consent. Compensation will be provided for participation, with withdrawal options available. Ethical considerations include ensuring participant confidentiality and addressing psychological disorders beyond exclusion criteria.

DISCUSSION

Understanding fluid-based biomarkers in IPV-related ABI can inform interdisciplinary interventions and precision care models. Findings may facilitate early detection, treatment, and safety planning for affected females, emphasizing the importance of tailored, accessible care for this vulnerable population. Future research should focus on translating these findings into evidence-based practice to improve outcomes for women with ABI, particularly those resulting from IPV.

Heterogeneity of health-related quality of life after mild traumatic brain injury with systemic injury: a cluster analytic approach

PURPOSE

Health-related quality of life (HRQoL) is a key component of evaluating outcome after mild traumatic brain injury (mTBI). As outcome is heterogeneous following mTBI, it is relevant to examine individual differences in HRQoL. This study investigated whether multiple homogenous subgroups could be meaningfully identified, 10 weeks after hospitalised mTBI with systemic injury, on the basis of HRQoL profiles.

METHODS

Ninety-one adults were assessed for HRQoL, pain, fatigue, sleep quality, psychological distress, cognition and post-concussion symptoms.

RESULTS

Cluster analyses revealed three separate subgroups based on physical, mental, social and energy HRQoL. One group (42%) demonstrated normative levels of HRQoL on all subdomains. The remaining two groups demonstrated significantly reduced HRQoL on all subdomains. These groups had equivalently poor mental, social and energy HRQoL, but the smallest group (27%) had significantly poorer physical HRQoL. Multinomial logistic regression revealed that pain significantly and independently predicted group membership for the particularly poor physical HRQoL group. Fatigue was the only significant independent predictor of group membership for the remaining group with reduced HRQoL.

CONCLUSION

These findings suggest more than 50% of hospitalised individuals with mTBI and systemic injury, have reduced HRQoL, 10 weeks after mTBI. Pain and fatigue warrant clinical attention in these individuals.IMPLICATIONS FOR REHABILITATIONMild traumatic brain injury is a common event that has been shown to be associated with persistently reduced health-related quality of life in approximately 50% of individuals 6 to 12 months after injury.Health-related quality of life likely varies between individuals after injuryRelative to the "normal" population, most individuals in this cohort of individuals with mTBI and systemic injury had reduced mental, social and energy quality of life 10 weeks after injury.Fatigue and pain are important factors in reduced health-related quality of life after mTBI with systemic injury.Further research is needed to determine whether these fatigue and pain issues are related to mTBI-factors, such as headache, and/or related to systemic injury factors, which are common in the mTBI population.

Genetic vulnerability and adverse mental health outcomes following mild traumatic brain injury: a meta-analysis of CENTER-TBI and TRACK-TBI cohorts

Background

Post-traumatic stress disorder (PTSD) and depression are common after mild traumatic brain injury (mTBI), but their biological drivers are uncertain. We therefore explored whether polygenic risk scores (PRS) derived for PTSD and major depressive disorder (MDD) are associated with the development of cognate TBI-related phenotypes.

Methods

Meta-analyses were conducted using data from two multicenter, prospective observational cohort studies of patients with mTBI: the CENTER-TBI study (ClinicalTrials.gov ID NCT02210221) in Europe (December 2014-December 2017) and the TRACK-TBI study in the US (March 2014-July 2018). In both cohorts, the most common causes of injury were road traffic accidents and falls. Primary outcomes, specifically probable PTSD and depression, were defined at 6 months post-injury using scores ≥33 on the PTSD Checklist-5 and ≥15 on the Patient Health Questionnaire-9, respectively. We calculated PTSD-PRS and MDD-PRS for patients aged ≥17 years who had a Glasgow Coma Scale score of 13-15 upon hospital arrival and assessed their association with PTSD and depression following TBI. We also evaluated the transferability of the findings in a cohort of African Americans.

Findings

Overall, 11.8% (219/1869) and 6.7% (124/1869) patients were classified as having probable PTSD and depression, respectively. The PTSD-PRS was significantly associated with higher adjusted odds of PTSD in both cohorts, with a pooled odds ratio (OR) of 1.55 [95% confidence interval (CI) 1.30-1.84, p < 0.001, I 2  = 20.8%]. Although the MDD-PRS increased the risk of depression after TBI, it did not reach significance in the individual cohorts. However, in a combined analysis, the risk was significantly elevated with a pooled OR of 1.26 [95% CI 1.03-1.53, p = 0.02, I 2  = 0%]. The addition of PRSs improved the proportion of outcome variance explained in the two study cohorts from 19.5% and 30.3% to 21.6% and 34.0% for PTSD; and from 11.0% and 22.5% to 12.8% and 22.6% for depression. Patients in the highest cognate PRS quintile had increased odds of 3.16 [95% CI 1.80-5.55] and 2.03 [95% CI 1.04-3.94] of developing PTSD or depression compared to the lowest quintile, respectively.

Interpretation

Associations of PRSs with PTSD and depression following TBI are not disorder-specific. However, the overlap between MDD-PRS and depression following TBI is less robust compared to PTSD-PRS and PTSD. PRSs could improve risk prediction, and permit enrichment for interventional trials.

Funding

This study was supported by funding by an FP7 grant from the European Union, Hannelore Kohl Stiftung, Integra LifeSciences Corporation, NeuroTrauma Sciences, US National Institutes of Health, US Department of Defense, National Football League Advisory Board, US Department of Energy, and One Mind.

What traditional neuropsychological assessment got wrong about mild traumatic brain injury. II: limitations in test development, research design, statistical and psychometric issues

PRIMARY OBJECTIVE

This is Part II of a four-part opinion review on traditional neuropsychological assessment methods and findings associated with mild traumatic brain injury (mTBI). This Part II review focuses on historical, psychometric and statistical issues involving traditional neuropsychological methods that have been used in neuropsychological outcome studies of mTBI, but demonstrates the critical limitations of traditional methods.

RESEARCH DESIGN

This is an opinion review.

METHODS AND PROCEDURES

Traditional neuropsychological tests are dated and lack specificity in evaluating such a heterogenous and complex injury as occurs with mTBI.

MAIN OUTCOME AND RESULTS

In this review, we demonstrate traditional neuropsychological methods were never developed as standalone measures for detecting subtle changes in neurocognitive or neurobehavioral functioning and likewise, never designed to address the multifaceted issues related to underlying mTBI neuropathology symptom burden from having sustained a concussive brain injury.

CONCLUSIONS

For neuropsychological assessment to continue to contribute to clinical practice and outcome literature involving mTBI, major innovative changes are needed that will likely require technological advances of novel assessment techniques more specifically directed to evaluating the mTBI patient. These will be discussed in Part IV.

Long-term Morbidity of Traumatic Brain Injury Following Facial Fracture

Background

Traumatic brain injury (TBI) is underreported in craniofacial trauma patients, and the long-term morbidity of TBI associated with craniofacial trauma is poorly defined. Current literature is limited in scope to TBI identification in the immediate posttrauma time frame.

Methods

A retrospective, cohort analysis of adult facial fracture patients presenting from February 2022 to February 2023 was performed. Data were collected for demographics, mechanism of injury, fracture pattern, Glasgow Coma Score, admission status, operative intervention, and concomitant injuries. Rivermead Post Concussion Symptoms Questionnaire surveys were given for evaluation of TBI symptoms at most recent follow-up. Statistical significance was accepted when the P value was less than 0.05.

Results

Of 232 facial fracture patients, 82 (35%) completed the Rivermead Post Concussion Symptoms Questionnaire. The mean age was 49.8 years, and mean follow-up time was 11.6 months (range, 2-22 mo). The rate of all patients with TBI symptoms at follow-up was 32.9%. Mechanism of injury, presence of multiple fractures, Glasgow Coma Score less than 15, concomitant injuries, and admission status were not significant predictors of TBI. Fractures requiring operative intervention had higher rates of TBI compared with nonoperative fractures (47.1% versus 22.9%, P = 0.02). Operative intervention was the only significant predictor of TBI symptoms at the time of follow-up (odds ratio: 6.268; 95% confidence interval: 1.322-29.744; P = 0.021) by multivariable logistic regression.

Conclusions

Craniofacial trauma is associated with persistent TBI symptoms. Surgeons treating this trauma population should screen for TBI to facilitate disease identification and specialty referral.

The Injury Progression in Acute Blast-Induced Mild Traumatic Brain Injury in Rats Reflected by Diffusion Tensor Imaging and Immunohistochemical Examination

Diffusion tensor imaging (DTI) has emerged as a promising neuroimaging tool for detecting blast-induced mild traumatic brain injury (bmTBI). However, lack of refined acute-phase monitoring and reliable imaging biomarkers hindered its clinical application in early diagnosis of bmTBI, leading to potential long-term disability of patients. In this study, we used DTI in a rat model of bmTBI generated by exposing to single lateral blast waves (151.16 and 349.75 kPa, lasting 47.48 ms) released in a confined bioshock tube, to investigate whole-brain DTI changes at 1, 3, and 7 days after injury. Combined assessment of immunohistochemical analysis, transmission electron microscopy, and behavioral readouts allowed for linking DTI changes to synchronous cellular damages and identifying stable imaging biomarkers. The corpus callosum (CC) and brainstem were identified as predominantly affected regions, in which reduced fractional anisotropy (FA) was detected as early as the first day after injury, with a maximum decline occurring at 3 days post-injury before returning to near normal levels by 7 days. Axial diffusivity (AD) values within the CC and brainstem also significantly reduced at 3 days post-injury. In contrast, the radial diffusivity (RD) in the CC showed acute elevation, peaking at 3 days after injury before normalizing by the 7-day time point. Damages to nerve fibers, including demyelination and axonal degeneration, progressed in lines with changes in DTI parameters, supporting a real-time macroscopic reflection of microscopic neuronal fiber injury by DTI. The most sensitive biomarker was identified as a decrease in FA, AD, and an increase in RD within the CC on the third day after injury, supporting the diagnostic utility of DTI in cases of bmTBI in the acute phase.

Small Molecule Drug C381 Attenuates Brain Vascular Damage Following Repetitive Mild Traumatic Injury

Traumatic brain injury (TBI) remains a significant public health concern, with no effective therapeutic interventions to ameliorate the enduring consequences. The prevailing understanding of TBI pathophysiology indicates a central role for vascular dysfunction. Transforming growth factor-β (TGF-β) is a multifunctional cytokine crucial for vascular development. Aberrant TGF-β signaling is implicated in vascular pathologies associated with various neurological conditions. We recently developed a novel small molecule drug, C381, a TGF-β activator with the ability to restore lysosomal function. Here we used a mouse model of repetitive mild TBI (mTBI) to examine whether C381 would attenuate vascular injury. We first employed RNA-seq analysis to investigate the gene expression patterns associated with mTBI and evaluated the therapeutic potential of C381 in mitigating these changes. Our results demonstrate distinct mTBI-related gene expression signatures, prominently implicating pathways related to vascular integrity and endothelial function. Notably, treatment with C381 reversed these mTBI-induced gene expression changes. Immunohistochemical analysis further corroborated these findings, revealing that C381 treatment attenuated vascular damage in mTBI-affected brain tissue. These findings strongly support the potential clinical usefulness of C381 as a novel therapeutic intervention for mTBI.

Metacognitive Therapy for People Experiencing Persistent Post-Concussion Symptoms Following Mild Traumatic Brain Injury: A Preliminary Multiple Case-Series Study

After mild traumatic brain injury (mTBI), a subgroup of individuals experience persistent post-concussion symptoms (PPCS) that include headaches, cognitive difficulties, and fatigue. The aim of this preliminary study was to investigate possible effects associated with metacognitive therapy (MCT) on PPCS, maladaptive coping strategies, and positive and negative metacognitive beliefs following mTBI. A pre-post design supplemented with single-case A-B replication series to assess potential MCT mechanisms was used. Of the nine participants who received MCT, all experienced a decrease in PPCS, which constituted a reliable improvement for eight participants. For eight participants (we could calculate effect sizes for eight out of nine participants), moderate to very large decreases in maladaptive coping styles and positive and negative metacognitive beliefs were observed. However, based on visual analyses, participants 6, 8, and 9 show a downward baseline trend regarding MCT mechanisms that may have persisted into the intervention phase. No adverse events were reported. In conclusion, MCT was associated with improvements in PPCS and unhelpful psychological mechanisms, but caution is required in interpreting this association. Future research using formal single-case replication on symptom measures and randomized controlled trials appears to be justified.

Pilot feasibility randomised controlled trial of cognitive-behavioural therapy for functional cognitive disorder after concussion

Background

Functional cognitive disorder (FCD) may be common after a concussion, and no evidence-based treatment options are available. The current study evaluated the feasibility of a novel cognitive-behavioural therapy (CBT) protocol tailored to FCD after concussion.

Methods

Participants were randomised to CBT (n=11) or the current standard of care, cognitive rehabilitation (n=13). Both interventions consisted of eleven 50 min manualised videoconference sessions. CBT involved cognitive reappraisal and exposure-based strategies. Cognitive rehabilitation involved traditional memory compensation strategy training. Prespecified feasibility criteria were set for recruitment, perceived credibility, patient adherence, therapist protocol compliance and retention. The primary efficacy outcome was the Multifactorial Memory Questionnaire-Satisfaction (MMQ-S). The first five CBT completers completed a semistructured interview about their experience with the intervention.

Results

Most feasibility benchmarks were met, as 86% of invited patients consented, 96% of participants rated their intervention as credible, participants attended 96% of sessions, therapists covered all essential content in 94% of sessions and 100% of participants completed the post-treatment evaluation. Both groups improved on the MMQ-S. Post-treatment MMQ-S scores were similar between groups (Cohen's d=-0.05 (95% CI [-0.86, 0.75])). Two themes resulted from the qualitative data analysis, which highlighted aspects of the CBT interventions that participants valued.

Implications

This pilot trial supports the feasibility of CBT tailored to FCD after concussion and suggests that patients with FCD may benefit from either CBT or standard cognitive rehabilitation. A larger trial is needed to evaluate the efficacy of these interventions for FCD after concussion and potentially FCD in other clinical contexts.

Trial registration number

NCT05581810.

Resilience and Concussion Recovery in Minority Women: Promoting Health Equity

Resilience is associated with the degree to which post-concussion symptoms (PCS) are experienced. However, the role of resilience in the recovery trajectory of minority women, who tend to have prolonged concussion recovery, is poorly characterized. We evaluated the association between resilience and PCS, to determine if the association differed by race. A secondary data analysis was performed. Resilience was assessed using the Resilience Scale and PCS with the Rivermead questionnaire. Both variables were evaluated 6-10 weeks post-injury. Baseline demographics, spearman correlation, and multivariable linear regression models were used to determine the association between resilience and PCS. Seventy-seven women (mean age 28 ± 7.6) were included, 57% were White, and 43% were Black or Hispanic. The overall cohort had a moderate association between resilience and PCS (R = -0.304, p = 0.007). The association was present in minorities (R = -0.486, p = 0.004), and was stronger for Blacks (R = -0.745, p < 0.001). After adjusting for religion as a covariate separately, resilience (β = -0.156, 95% confidence interval [CI]: -0.285, -0.026; p = 0.019) and mood (β = 1.082, 95% CI: 0.847, 1.317; p < 0.001), were both independent predictors of PCS. The adjusted associations were stronger for the minority subgroup for both resilience (β = -0.231, 95% CI: -0.413, -0.050; p = 0.014) and mood (β = 1.122, 95% CI: 0.753, 1.491; p < 0.001). Our findings show that compared with Whites, minority individuals with higher resilience have greater resolution of PCS. However, mood is also of importance in this association. Thus resilience-based interventions must also target mood. Interventions that strengthen resilience may have promise in promoting equitable recovery in the setting of female concussions.

Effects of mTBI with loss of consciousness on neurobehavioral symptoms, depression, and insomnia in former collegiate and NFL football athletes

OBJECTIVE

Considering that diagnostic decisions about mTBI are often predicated on clinical symptom criteria, it is imperative to determine which initial presentation features of mTBI have prognostic significance for identifying those at high risk for long-term functional impairment.

SETTING

Zoom interview Participants: Male, former NCAA Division I, and professional-level National Football League (NFL) athletes (n = 177) between the ages of 27 and 85 (M = 54.1, SD = 14.7).

DESIGN

Cross-sectional case-control. Main Measures: History of mild TBI, history of loss of consciousness (LOC), depression symptoms, insomnia, neurobehavioral symptoms.

RESULTS

Number of mTBI exposures did not predict neurobehavioral symptoms (B = 0.21, SE = 0.18, p = 0.23), but number of mTBI + LOC events did (B = 2.27, SE = 0.64, p = <.001). Further analysis revealed that the number of mTBI + LOC events predicted neurobehavioral symptoms indirectly through both depression (B = 0.85, 95% CI = [0.27, 1.52) and insomnia (B = 0.81, 95% CI = [0.3, 1.4]). Further, the direct effect of mTBI + LOC events on neurobehavioral symptoms became non-significant when depression and insomnia were added to the model (B = 0.78, SE = 0.45, p = 0.08).

CONCLUSIONS

Findings support LOC at time of injury as an important predictor of long-term outcomes. Additionally, results suggest depression and insomnia as potential mediators in the association between mTBI + LOC and neurobehavioral symptoms. These findings provide justification for early depression and insomnia symptom monitoring following mTBI + LOC.

Impact of obese body mass index on inflammasome blood biomarkers and neurocognitive performance following traumatic brain injury with Glasgow coma scale 13 to 15

Activation of the NOD-like receptor family pyrin domain-containing 3 (NLRP3) inflammasome is a moderating factor between obesity and cognitive impairment in animals, but this has never been tested in humans following mild traumatic brain injury (mTBI). This is a retrospective cohort analysis of subjects enrolled at a single level 1 trauma center (n = 172). Participants completed Trail Making Test Part A and B (TMT-A and B) at six- and twelve-months, Blood samples were obtained within 24 h of mTBI and apoptosis-associated speck-like protein containing a caspase recruitment domain (ASC), caspase-1, interleukin-18 (IL-18), and IL-1β were assayed. Obese participants (BMI = 30-34.9) were associated with higher IL-18 (p = 0.03) and IL-1β (p = 0.05) and severely obese participants (BMI > 35.0) were associated with higher IL-1β (p = 0.005) than healthy weight participants. IL-1β was associated with TMT-A at six- (p = 0.01) and twelve-months (p = 0.03) and TMT-B at twelve-months (p = 0.046). The interaction of severely obese BMI and IL-1β was associated with TMT-B at six- (p = 0.049) and twelve-months (p = 0.02). ASC (p = 0.03) and the interaction of ASC with severely obese BMI was associated with TMTB at six- (p = 0.02) and twelve-months (p = 0.02). Obesity may augment acute inflammasome response to mTBI and influence worse long-term cognitive outcomes up to one-year post-injury.

HISTOLOGICAL COMPARISON OF REPEATED MILD WEIGHT DROP AND LATERAL FLUID PERCUSSION INJURY MODELS OF TRAUMATIC BRAIN INJURY IN FEMALE AND MALE RATS

ABSTRACT

In preclinical traumatic brain injury (TBI) research, the animal model should be selected based on the research question and outcome measures of interest. Direct side-by-side comparisons of different injury models are essential for informing such decisions. Here, we used immunohistochemistry to compare the outcomes from two common models of TBI, lateral fluid percussion (LFP) and repeated mild weight drop (rmWD) in adult female and male Wistar rats. Specifically, we measured the effects of LFP and rmWD on markers of cerebrovascular and tight junction disruption, neuroinflammation, mature neurons, and perineuronal nets in the cortical site of injury, cortex adjacent to injury, dentate gyrus, and the CA 2/3 area of the hippocampus. Animals were randomized into the LFP or rmWD group. On day 1, the LFP group received a craniotomy, and on day 4, injury (or sham procedure; randomly assigned). The rmWD animals underwent either injury or isoflurane only (randomly assigned) on each of those 4 days. Seven days after injury, brains were harvested for analysis. Overall, our observations revealed that the most significant disruptions were evident in response to LFP, followed by craniotomy only, whereas rmWD animals showed the least residual changes compared with isoflurane-only controls, supporting consideration of rmWD as a mild injury. LFP led to longer-lasting disruptions, perhaps more representative of moderate TBI. We also report that craniotomy and LFP produced greater disruptions in females relative to males. These findings will assist the field in the selection of animal models based on target severity of postinjury outcomes and support the inclusion of both sexes and appropriate control groups.

A supported primary health pathway for mild traumatic brain injury quality improvement report

Introduction Best-practice guidelines recommend that patients are followed-up to check if they have recovered following a mild traumatic brain injury (mTBI) and to refer to concussion services, if needed. However, in New Zealand, rates of follow-up are low and access to concussion services can be delayed. Aim We aimed to improve rates of follow-up and access to concussion services for mTBI patients aged ≥8 years by the implementation of a supported health pathway and test its success. Methods The pathway included a decision support tool, funded follow-up appointments, clinician training and a patient education resource. Sociodemographics, injury details and proportions of patients receiving a follow-up by type and time were extracted from the Accident Compensation Corporation (ACC) database between 18 May 22 and 30 June 23 and compared to national ACC data prior to implementation. Results Data were extracted for 220 patients, with a mean age of 31.5 years, 51.4% female and 21.4% Māori and Pacific. There was an increase in the proportion of patients receiving a follow-up from 36% pre-implementation to 56.8% post-implementation. Sixty-three patients (28.6%) accessed a concussion service post-implementation compared to 10% pre-implementation. Time to concussion service reduced from an average of 55 (s.d. = 65.4) to 37 days (29.5). Discussion Risk factor criteria within the decision support tool need to be weighted to improve specificity of referrals. Timing from injury to medical review in primary care needs to be considered. This quality improvement project provides preliminary evidence for implementation of a supported health care pathway for mTBI.

Association of early blood-based biomarkers and six-month functional outcomes in conventional severity categories of traumatic brain injury: capturing the continuous spectrum of injury

BACKGROUND

Traumatic brain injury is conventionally categorised as mild, moderate, or severe on the Glasgow Coma Scale (GCS). Recently developed biomarkers can provide more objective and nuanced measures of the extent of brain injury.

METHODS

Exposure-response relationships were investigated in 2479 patients aged ≥16 enrolled in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) prospective observational cohort study. Neurofilament protein-light (NFL), ubiquitin carboxy-terminal hydrolase L1 (UCH-L1), and glial fibrillary acidic protein (GFAP) were assayed from serum sampled in the first 24 h; concentrations were divided into quintiles within GCS severity groups. Relationships with the Glasgow Outcome Scale-Extended were examined using modified Poisson regression including age, sex, major extracranial injury, time to sample, and log biomarker concentration as covariates.

FINDINGS

Within severity groups there were associations between biomarkers and outcomes after adjustment for covariates: GCS 13-15 and negative CT imaging (relative risks [RRs] from 1.28 to 3.72), GCS 13-15 and positive CT (1.21-2.81), GCS 9-12 (1.16-2.02), GCS 3-8 (1.09-1.94). RRs were associated with clinically important differences in expectations of prognosis. In patients with GCS 3 (RRs 1.51-1.80) percentages of unfavourable outcome were 37-51% in the lowest quintiles of biomarker levels and reached 90-94% in the highest quintiles. Similarly, for GCS 15 (RRs 1.83-3.79), the percentages were 2-4% and 19-28% in the lowest and highest biomarker quintiles, respectively.

INTERPRETATION

Conventional TBI severity classification is inadequate and underestimates heterogeneity of brain injury and associated outcomes. The adoption of circulating biomarkers can add to clinical assessment of injury severity.

FUNDING

European Union 7th Framework program (EC grant 602150), Hannelore Kohl Stiftung, One Mind, Integra LifeSciences, Neuro-Trauma Sciences, NIHR Rosetrees Trust.

Identification of At-Risk Patients That Need More Intensive Treatment Following mTBI: Post-Hoc Insights From the UPFRONT-Study

OBJECTIVE

To investigate which factors within an at-risk group make patients less likely to benefit from preventive treatment following mild traumatic brain injury (mTBI).

SETTING

Inclusion in 3 level I trauma centers in the Netherlands. Data collection through surveys as outpatients.

PARTICIPANTS

mTBI patients (18-66 years), reporting 3 or more complaints 2 weeks postinjury (at-risk status). Eighty-four patients included and randomized (39 patients cognitive behavioral therapy, 45 patients telephonic counseling). Eighty patients filled out the questionnaires 12 months postinjury. Post hoc analysis investigating 80 patients as 1 at-risk group receiving psychological treatment.

DESIGN

Post hoc study of a randomized controlled trial (RCT). Binomial logistic regression performed determining which variables 2 weeks postinjury contributed strongly to unsuccessful return to work/study (RTW) and unfavorable outcome at 12 months.

MAIN MEASURES

RTW and functional outcome as measured with the Glasgow Outcome Scale-Extended (GOSE) at 12 months postinjury.

RESULTS

Out of 80 patients, 43 (53.8%) showed a favorable functional outcome at 12 months, and 56 (70%) patients had a full RTW. Patients with unfavorable outcome had a higher age and higher reports of anxiety, depression at 2 weeks and 12 months postinjury. Patients with an unsuccessful RTW had a higher age and higher reports of depression, and posttraumatic stress disorder at 2 weeks and 12 months postinjury. A logistic regression model for functional outcome (GOSE) was statistically significant (χ² 7 = 40.30, P < .0001). Of 6 predictor variables, 3 were significant: anxiety, depression, and treatment condition. For RTW, logistic regression was also statistically significant (χ² 7 = 19.15, P = .008), with only 1 out of 6 predictor variables (ie, age) being significant.

CONCLUSION

Main findings comprise differences in demographic and psychological measures between patients with favorable and unfavorable outcomes and patients with RTW versus no RTW. Prediction models of outcome and RTW showed several psychological measures at 2 weeks greatly determining patients' likelihood benefitting from the preventive treatment. Results suggest that from the beginning there are some patients for whom a short preventive treatment is not sufficient. Selection and treatment of at-risk patients might be better based on psychological symptoms instead of posttraumatic complaints.

Neurobehavioral Symptoms in Spanish-Speaking Individuals With Subconcussive Injuries

OBJECTIVE

To examine whether exposure to high-risk events causing injury to the head or neck has an effect on neurobehavioral symptoms in the absence of an alteration of consciousness in Spanish-speakers.

SETTING

Web-based survey.

PARTICIPANTS

Seven hundred forty-eight individuals from Spain and Latin America, aged 18 to 65 years, with 10 years or more of education. Thirty-nine participants failed quality checks and were excluded. Seven hundred nine participants were included in the analyses.

DESIGN

Cross-sectional study. Subconcussive exposure was defined as endorsing exposure to one or more high-risk scenarios in the absence of any alteration of consciousness. Three injury groups were derived: No Head Injury, Subconcussive Exposure, and traumatic brain injury (TBI). The Subconcussive Exposure group was further divided into Single and Multiple Exposures. Two analyses were conducted: the effect of lifetime exposure to injury (No Head Injury, Subconcussive Exposure, TBI) on neurobehavioral symptoms; the effect of Subconcussive Exposure Frequency (No Head Injury, Single Exposure, Multiple Exposures) on neurobehavioral symptoms.

MAIN MEASURES

Spanish Ohio State University Traumatic Brain Injury Identification Method Self-Administered-Brief (OSU TBI-ID SAB); Neurobehavioral Symptom Inventory (NSI).

RESULTS

There was a significant effect for Injury group on the NSI partial eta-squared (η p2 = 0.053) and a significant effect of Exposure Frequency group on the NSI (η p2 = 0.40). Individuals with subconcussive exposures reported significantly more neurobehavioral symptoms than those with no history of head injury and significantly less symptoms than those with TBI. Individuals with multiple subconcussive exposures reported significantly more neurobehavioral symptoms than those with single and no exposure.

CONCLUSION

This research expands the utility of the OSU-TBI-ID SAB as a lifetime TBI history assessment tool to one capable of evaluating subconcussive exposure dosing effects in Spanish-speakers. Such an index may facilitate establishment of subconcussive exposure prevalence rates worldwide, leading to improved understanding of the chronic effects of high-risk exposures.

Can We Actually Predict Long-Term Patient Satisfaction After Traumatic Brain Injury?

INTRODUCTION

The Traumatic Brain Injury - Patient Reported Outcome (TBI-PRO) model was previously derived to predict long-term patient satisfaction as assessed by the Quality of Life After Brain Injury (QOLIBRI) score. The aim of this study is to externally and prospectively validate the TBI-PRO model to predict long-term patient-reported outcomes and to derive a new model using a larger dataset of older adults with TBI.

METHODS

Patients admitted to a Level I trauma center with TBI were prospectively followed for 1 y after injury. Outcomes predicted by the TBI-PRO model based on admission findings were compared to actual QOLIBRI scores reported by patients at 3,6, and 12 mo. When deriving a new model, Collaborative European NeuroTrauma Effectiveness Research in TBI and the Transforming Research and Clinical Knowledge in Traumatic Brain Injury databases were used to identify older adults (≥50 y) with TBI from 2014 to 2018. Bayesian additive regression trees were used to identify predictive admission covariates. The coefficient of determination was used to identify the fitness of the model.

RESULTS

For prospective validation, a total of 140 patients were assessed at 3 mo, with follow-up from 69 patients at 6 mo and 13 patients at 12 mo postinjury. The area under receiver operating curve of the TBI-PRO model for predicting favorable outcomes at 3, 6, and 12 mo were 0.65, 0.57, and 0.62, respectively. When attempting to derive a novel predictive model, a total of 1521 patients (80%) was used in the derivation dataset while 384 (20%) were used in the validation dataset. A past medical history of heart conditions, initial hospital length of stay, admission systolic blood pressure, age, number of reactive pupils on admission, and the need for craniectomy were most predictive of long-term QOLIBRI-Overall Scale. The coefficient of determination for the validation model including only the most predictive variables were 0.28, 0.19, and 0.27 at 3, 6, and 12 mo, respectively.

CONCLUSIONS

In the present study, the prospective validation of a previously derived TBI-PRO model failed to accurately predict a long-term patient reported outcome measures in TBI. Additionally, the derivation of a novel model in older adults using a larger database showed poor accuracy in predicting long-term health-related quality of life. This study demonstrates limitations to current targeted approaches in TBI care. This study provides a framework for future studies and more targeted datasets looking to assess long-term quality of life based upon early hospital variables and can serve as a starting point for future predictive analysis.

Predicting recovery in patients with mild traumatic brain injury and a normal CT using serum biomarkers and diffusion tensor imaging (CENTER-TBI): an observational cohort study

Background

Even patients with normal computed tomography (CT) head imaging may experience persistent symptoms for months to years after mild traumatic brain injury (mTBI). There is currently no good way to predict recovery and triage patients who may benefit from early follow-up and targeted intervention. We aimed to assess if existing prognostic models can be improved by serum biomarkers or diffusion tensor imaging metrics (DTI) from MRI, and if serum biomarkers can identify patients for DTI.

Methods

We included 1025 patients aged >18 years with a Glasgow Coma Score >12 and normal CT from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study which recruited between December 19,2014 and December 17, 2017 (NCT02210221). Biomarkers (GFAP, NFL, S100B) were obtained at a median of 8.8 h (Q1-Q3 4.2-16.7) and DTI at 13 days (3-19) after injury. DTI metrics were available in 153 patients for 48 white matter tracts (ICBM-DTI-81 atlas). Incomplete recovery at three months was defined as an extended Glasgow Outcome Scale score <8. Existing prognostic models were fitted with and without biomarkers, or with and without DTI, and internally validated using bootstrapping.

Findings

385 (38%) patients had incomplete recovery. Adding biomarkers did not improve performance beyond the best existing clinical prognostic model [optimism-corrected AUC 0.69 (95% CI 0.65-0.72) and R2 17% (11-22)]. Adding DTI metrics significantly enhanced all models [best optimism-corrected AUC 0.82 (0.79-0.85) and R2 75% (39-100)]. The top three prognostic tracts were the left posterior thalamic radiation, left superior cerebellar peduncle and right uncinate fasciculus. Serum biomarkers could have avoided 1 in 5 DTI scans, with GFAP <12 h and NFL 12-24 h from injury performing best.

Interpretation

DTI substantially improved existing prognostic models for functional outcome in patients with mTBI and a normal CT, and biomarkers could help select patients for MRI. If validated, DTI could allow for targeted follow-up and enrichment of clinical trials of early interventions to improve outcome.

Funding

EU Seventh Framework Programme, Hannelore Kohl Stiftung, One Mind, Integra LifeSciences, NeuroTrauma Sciences.

Self-Reported Traumatic Brain Injury and Its Biopsychosocial Risk Factors in Siblings of Individuals with Neurodevelopmental Conditions

Siblings of individuals with neurodevelopmental conditions (NDCs) are situated within a complex system of risk and resilience factors for poor outcomes, many of which overlap with the risk of traumatic brain injury (TBI) and correlate with poorer recovery trajectories. This study used Bayesian analyses to characterize and compare TBI and biopsychosocial risk factors among 632 siblings (207 NDC, 425 controls; mean age 20.54 years, range 10-30, 78.48% female). NDC siblings had a higher self-reported lifetime history of TBI compared to controls (14.98% versus 6.35%), with most reporting more than one TBI, and at an earlier age. TBI history was associated with psychiatric diagnoses and subclinical NDC features. Family and structural factors related to TBI included poorer parent-child relationship, NDC diagnoses of autism or fetal alcohol spectrum disorder, minority ethnicity, and lower income. Findings have implications for health literacy, TBI education and screening, and implementation of family support.

Impact of traumatic brain injury on risk for schizophrenia and bipolar disorder

The impact of traumatic brain injury (TBI) on subsequent risk of schizophrenia (SCZ) or bipolar disorder (BD) remains contested. Possible genetic and environmental confounding effects have also been understudied. Therefore, we aim to investigate the impact of TBI on the risk of SCZ and BD and whether the effect varies by injury severity, age at injury, and sex. We identified 4,184 SCZ and 18,681 BD cases born between 1973 and 1998 in the Swedish National Registers. Case-control samples matched (1:5) on birth year, sex, and birthplace were created along with a family design study, with cases matched to non-case full siblings. TBI was associated with higher risk of SCZ and BD (IRR=1.33 for SCZ, IRR=1.78 for BD). The association remained significant in the sibling comparison study. Moderate or severe TBI was associated with higher risk for both SCZ and BD compared to mild TBI. Older age at injury was associated with higher risk of SCZ and BD, and the effect of TBI was stronger in women than men. Findings indicate that TBI is a risk factor for both SCZ and BD with differential impact by age, severity and sex and that this association cannot be explained by familial confounding alone.

Symptom Persistence Relates to Volume and Asymmetry of the Limbic System after Mild Traumatic Brain Injury

Background: Persistent symptoms have been reported in up to 50% of the 27 million people with mild traumatic brain injuries (mTBI) every year. MRI findings are currently limited by low diagnostic and prognostic sensitivities, constraining the value of imaging in the stratification of patients following mTBI. Limbic system structures are promising brain regions in offering prognostic factors for symptom persistence following mTBI. The objective of this study was to associate volume and symmetry of limbic system structures with the presence and persistence of common symptoms in patients with mTBI. Methods: This study focused on 524 adults (aged 18-82), 58% female, with 82% injured in motor vehicle accidents and 28% reporting loss of consciousness (LOC). Magnetic resonance imaging (MRI) data included a sagittal 3D T1-weighted sequence with 1.2 mm slice thickness, with voxel sizes of 0.93 mm × 0.93 mm × 1.2 mm, obtained a median of 156 days after injury. Symptom diagnosis and persistence were collected retrospectively from patient medical records. Intracranial volume-adjusted regional volumes per side utilizing automated volumetric analysis (NeuroQuant®) were used to calculate total volume, laterality index, and side-independent asymmetry. Covariates included age, sex, LOC, and days from injury. Limbic volumetrics did not relate to symptom presentation, except the (-) association between headache presence and thalamus volume (adjusted odds ratio = 0.51, 95% confidence interval = 0.32, 0.85). Headache, balance problems, anxiety, and depression persistence was (-) associated with thalamus volume (hazard ratio (HR) 1.25 to 1.94). Longer persistence of balance problems was associated with (-) lateral orbitofrontal cortex volume (HR = 1.33) and (+) asymmetry of the hippocampus (HR = 0.27). Persistence of cognitive deficits was associated with (+) asymmetry in the caudal anterior cingulate (HR = 0.67). Depression persistence was associated with (+) asymmetry in the isthmus of the cingulate gyrus (HR = 5.39). Persistence of anxiety was associated with (-) volume of the parahippocampal gyrus (HR = 1.67), orbitofrontal cortex (HR > 1.97), and right-biased laterality of the entorhinal cortex (HR = 0.52). Conclusions: Relative volume and asymmetry of the limbic system structures in patients with mTBI are associated with the persistence of symptoms, particularly anxiety. The conclusions of this study are limited by the absence of a reference group with no mTBI.

Mild traumatic brain injury caused by workplace violence in a US workers' compensation system

OBJECTIVES

Approximately 81% of traumatic brain injury cases are considered to be mild (mTBI), but few studies have reviewed mTBI caused by workplace violence (WPV). This study aimed to (1) determine the incidence of mTBI secondary to WPV in a statewide workers' compensation system using International Classification of Disease codes and (2) analyse and compare factors associated with return-to-work outcomes between WPV mTBI cases versus other mechanisms.

METHODS

Using a retrospective cohort of claims data from the California Workers' Compensation Information System during 2015-2019, cases with a return-to-work date were classified as WPV if the injury description contained keywords such as assault, gunpoint, harassed, intimidated, punch, threat, robbery, violent or verbal abuse.

RESULTS

Of the 14 089 mTBI claims analysed in this study, 11.2% were caused by WPV. When comparing WPV to non-WPV claims, the variables with statistically significant (p≤0.001) differences were age, income, industry and job class. There were no significant differences between groups for leave duration. In a linear mixed model, the variable of interest (WPV) was not associated with recovery duration after adjusting for other factors.

CONCLUSION

To our knowledge, this is the first study to examine WPV mTBI claims in the USA. The findings suggest that the public administration, education and healthcare and social services industries are at higher risk for WPV mTBI. WPV and job class were the only modifiable factors in the model and therefore should be the focus of additional research.

Team-based rehabilitation after mild traumatic brain injury - description of the clinical pathway

PURPOSE

Describe clinical practice, inter-disciplinary clinical pathway and core principles of care within a mild traumatic brain injury (mTBI) rehabilitation team.

METHODS

An observational study examined inter-disciplinary practice, nested within an observational trial investigating team-based mTBI rehabilitation. Data were collected to describe clinical service over 12 months. Activity data quantified clinical sessions per participant, mode of service delivery and content of sessions using custom-designed codes. The clinical team gathered narrative data to confirm the inter-disciplinary clinical pathway and individual discipline practice.

RESULTS

168 participants entered the rehabilitation program during the 12 months. A single Allied Health Screening Assessment identified patient priorities. Occupational Therapy (OT) and Physiotherapy (PT) provided the majority of clinical sessions; the team also comprised Social Work, Rehabilitation Medicine, Speech Pathology and Clinical Psychology. Telehealth was the most common service delivery mode (54%). Median session numbers per participant ranged 1-4 for all disciplines; mean/maximum occasions of service were highest for PT (6.9/44) and OT (6.8/39).

CONCLUSION

A small proportion of participants received much higher number of sessions, consistent with intractable issues after mTBI. High attendance rates indicate the predominantly telehealth-delivered model was feasible. The clinical approach included early prioritizing of discipline input and follow-up after discharge.

Use of the Buffalo Concussion Treadmill Test in community adult patients with mild traumatic brain injury

BACKGROUND

The Buffalo Concussion Treadmill Test (BCTT) is used to establish exercise tolerance for rehabilitation and identify injury subtypes for youth athletes after mild traumatic brain injury (mTBI). Its utility in adult community members is unknown.

OBJECTIVE

Primary: To describe how adults with and without mTBI tolerate the BCTT. Secondary: To explore relationships between baseline factors, mTBI-related symptoms, and BCTT duration.

DESIGN

Prospective, observational, longitudinal.

SETTING

Academic medical center.

PARTICIPANTS

Thirty-seven adults treated in a level 1 trauma center emergency department with mTBI;  24 uninjured controls (UC).

INTERVENTIONS

N/A.

MAIN MEASURES

Participants completed two visits 3 weeks apart (1 week and 1 month after mTBI) including a 15-minute BCTT, the Rivermead Post Concussion Symptoms Questionnaire (RPQ), and preinjury International Physical Activity Questionnaire. Analyses characterized BCTT response and associations between baseline factors, RPQ scores, and BCTT duration.

RESULTS

Persons with mTBI discontinued earlier than UC at 1-week postinjury using standard discontinuation criteria for exercise intolerance. The percentage of mTBI participants with signs of possible mTBI-related intolerance was 55.6% at 1 week (36.1% for mTBI-related symptom exacerbation, 19.4% for exertion/fatigue before reaching 85% of one's age-predicted maximum heart rate [HR]) and 48.0% at 1 month (40.0% mTBI-related symptom exacerbation, 8.0% exertion without reaching the target HR). Thirty percent of UCs completed the BCTT at both assessments. UCs met discontinuation criteria for increased nonspecific symptoms (eg, pain/general discomfort and increased Visual Analog Scale ratings; 39-61%) and physical exertion (9-26%). Shorter duration was associated with higher body mass index (r = -0.42 - -0.45), shorter height (r = 0.22-0.29), female gender (r = -0.26 - -0.27), and greater RPQ symptoms (r = -0.28 - -0.47).

CONCLUSION

The BCTT exacerbates mTBI-related symptoms in adult community members. Participant characteristics and noninjury factors influence performance. The findings imply the BCTT could be useful in clinical assessments of adults with mTBI. Interpretation should account for the unique characteristics of nonathletes.