Mild traumatic brain injury after motor vehicle collisions: what are the symptoms and who treats them? A population-based 1-year inception cohort study

The Prevalence and Influence of New or Worsened Neck Pain After a Sport-Related Concussion in Collegiate Athletes: A Study From the CARE Consortium

BACKGROUND

Neck pain in a concussion population is an emerging area of study that has been shown to have a negative influence on recovery. This effect has not yet been studied in collegiate athletes.

HYPOTHESIS

New or worsened neck pain is common after a concussion (>30%), negatively influences recovery, and is associated with patient sex and level of contact in sport.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Varsity-level athletes from 29 National Collegiate Athletic Association member institutions as well as nonvarsity sport athletes at military service academies were eligible for enrollment. Participants completed a preseason baseline assessment and follow-up assessments at 6 and 24 to 48 hours after a concussion, when they were symptom-free, and when they returned to unrestricted play. Data collection occurred between January 2014 and September 2018.

RESULTS

A total of 2163 injuries were studied. New or worsened neck pain was reported with 47.0% of injuries. New or worsened neck pain was associated with patient sex (higher in female athletes), an altered mental status after the injury, the mechanism of injury, and what the athlete collided with. The presence of new/worsened neck pain was associated with delayed recovery. Those with new or worsened neck pain had 11.1 days of symptoms versus 8.8 days in those without (P < .001). They were also less likely to have a resolution of self-reported symptoms in ≤7 days (P < .001). However, the mean duration of the return-to-play protocol was not significantly different for those with new or worsened neck pain (7.5 ± 7.7 days) than those without (7.4 ± 8.3 days) (P = .592).

CONCLUSION

This novel study shows that neck pain was common in collegiate athletes sustaining a concussion, was influenced by many factors, and negatively affected recovery.

Circumstances and outcome of active transportation injuries: protocol of a British Columbian inception cohort study

INTRODUCTION

Active transport (AT) is promoted by urban planners and health officials for its environmental, economic and societal benefits and its uptake is increasing. Unfortunately, AT users can be injured or killed due to falls or collisions. Active transport injury (ATI) prevention efforts are hindered by limited research on the circumstances, associated infrastructure, injury pattern, severity and outcome of ATI events. This study seeks to address these knowledge gaps by identifying built environment features associated with injury and risk factors for a poor outcome following ATI.

METHODS AND ANALYSIS

This prospective observational study will recruit an inception cohort of 2000 ATI survivors, including pedestrians, cyclists and micromobility users aged 16 years and older who arrive at a participating emergency department within 48 hours of sustaining an ATI. Baseline interviews capture demographic and socioeconomic information, pre-injury health and functional status, as well as circumstances of the injury event and recovery expectations. Follow-up interviews at 2, 4, 6 and 12 months postinjury (key stages of recovery) use standardised health-related quality of life tools to determine physical and mental health outcomes, functional recovery and healthcare resource use and lost productivity costs.

ETHICS AND DISSEMINATION

The Active Transportation Injury Circumstances and Outcome Study is approved by our institutional research ethics board and the research ethics boards of all participating sites. This study aims to provide healthcare providers with knowledge of risk factors for poor outcome following ATI with the goal of improving patient management. Additionally, this study will provide insight into the circumstances of ATI events including built environment features and how those circumstances relate to recovery outcomes. This information can be used to inform city engineers and planners, policymakers and public health officials to plan roadway design and injury prevention policy.

Prospective Blood Transcriptomics Study in a Motor Vehicle Collision Cohort Identified a Protective Function of the SAMD15 Gene Against Chronic Pain

Traumatic brain injuries following motor vehicle collisions (MVCs) are ubiquitous. Surprisingly, there are no correlates between concussion impact force and long-term pain outcomes. To study the molecular underpinnings of chronic pain after MVC, we assembled a prospective cohort of 36 subjects that experienced MVC and suffered documented mild traumatic brain injuries. For each participant, a first blood sample was drawn within 72 hours of the collision, then a second one at the 6-month mark. Pain was also assessed at the second blood draw to determine if pain became chronic or resolved. Blood samples enabled transcriptomics analyses for immune cells. At the transcriptome-wide level, we found that Sterile Alpha Motif Domain Containing 15 (SAMD15) mRNA was significantly upregulated with time in subjects who resolved their pain whereas unregulated in those with persistent pain. Using several large publicly available datasets, such as the UK Biobank and the GTeX portal, we then linked elevated SAMD15 gene expression, elevated neutrophils cell counts, and decreased risk for chronic pain to increased dosage of the T allele at SNP rs4903580, situated within SAMD15's gene locus. The causality between the components of our model was established and supported by Mendelian randomization. Overall, our results support the role of SAMD15 as a potential gene effector for neutrophil-dependent chronic pain development. PERSPECTIVE: This article highlights the potential protective role of the SAMD15 gene against chronic pain following a mild traumatic brain injury. The expression of the gene is associated with a SNP rs4903580, which is itself associated with neutrophils counts as well as chronic pain in large genetic studies.

Demographic and clinical profile of an inception cohort of road trauma survivors

BACKGROUND

Road trauma is a major public health concern, often resulting in reduced health-related quality of life and prolonged absenteeism from work even after so-called 'minor' injuries that do not result in hospitalization. This manuscript compares pre-injury health, sociodemographic characteristics and injury details between age, sex, and road user categories in a cohort of 1,480 road trauma survivors.

METHODS

This was a prospective observational inception cohort study of road trauma survivors recruited between July 2018 and March 2020 from three trauma centres in British Columbia, Canada. Participants were aged ≥ 16 years and arrived in a participating emergency department within 24 h of involvement in a motor vehicle collision. Data were collected from structured interviews and review of medical records.

RESULTS

The cohort of 1,480 road trauma survivors included 280 pedestrians, 174 cyclists, 118 motorcyclists, 683 motor vehicle drivers, and 225 passengers. Median age was 40 (IQR = [27, 57]) years; 680 (46%) were female. Males and younger patients were significantly more likely to report better pre-injury physical health. Motorcyclists and cyclists tended to report better physical health and less severe somatic symptoms, whereas pedestrians and motor vehicle drivers reported better mental health. Injury severity and hospital admission rates were higher in pedestrians and motorcyclists and lower in motorists. Upper and lower extremity injuries were most common in pedestrians, cyclists and motorcyclists, whereas neck injuries were most common in motor vehicle drivers and passengers.

CONCLUSIONS

In a large cohort of road trauma survivors, overall injury severity was low. Motorcyclists and pedestrians, but not cyclists, had more severe injuries than motorists. Extremity injuries were more common in vulnerable road users. Future research will investigate one-year recovery outcomes and identify risk factors for poor recovery.

Dizziness-Related Disability One Year after a Mild-to-Moderate TBI-A Follow-Up Study

Persisting dizziness and balance problems after mild-to-moderate traumatic brain injury (mmTBI) may result in considerable disability. The primary aim of this study was to explore the factors associated with dizziness-related disability one year post-injury. Data from 64 participants (mean age 39.4 [SD 13.0] years; 45 [70.3%] women) with mmTBI from a previous randomised controlled trial were analysed using simple and multiple regression analyses (Clinical Trials Registry #NCT01695577). The Dizziness Handicap Inventory one year (12.1, [SD1.6] months) post-injury was the dependent variable. Demographic and injury-related variables, clinical findings, and measures of post-injury symptoms and functioning (Rivermead Post-Concussion Symptoms Questionnaire, RPQ; Vertigo Symptom Scale-short form, VSS-SF; Hospital Anxiety and Depression Scale; Balance Error Scoring System; and High-Level Mobility Assessment Tool, HiMAT) at baseline (3.5 [SD 2.1] months post-injury) were the independent variables. Dizziness-related disability at one year was associated with pre-injury comorbidity, neck pain, higher RPQ, higher VSS-SF, and lower HiMAT scores (adjusted R2 = 0.370, F = 6.52 p < 0.001). In conclusion, the factors associated with dizziness-related disability one year post-injury, such as pre-injury comorbidity, neck pain, increased post-concussion symptom burden, increased dizziness symptom severity, and reduced balance and mobility, should be addressed early in the rehabilitation process to reduce patient burden.

Structural brain connectivity predicts early acute pain after mild traumatic brain injury

ABSTRACT

Mild traumatic brain injury (mTBI), is a leading cause of disability worldwide, with acute pain manifesting as one of its most debilitating symptoms. Understanding acute postinjury pain is important because it is a strong predictor of long-term outcomes. In this study, we imaged the brains of 157 patients with mTBI, following a motorized vehicle collision. We extracted white matter structural connectivity networks and used a machine learning approach to predict acute pain. Stronger white matter tracts within the sensorimotor, thalamiccortical, and default-mode systems predicted 20% of the variance in pain severity within 72 hours of the injury. This result generalized in 2 independent groups: 39 mTBI patients and 13 mTBI patients without whiplash symptoms. White matter measures collected at 6 months after the collision still predicted mTBI pain at that timepoint (n = 36). These white matter connections were associated with 2 nociceptive psychophysical outcomes tested at a remote body site-namely, conditioned pain modulation and magnitude of suprathreshold pain-and with pain sensitivity questionnaire scores. Our findings demonstrate a stable white matter network, the properties of which determine an important amount of pain experienced after acute injury, pinpointing a circuitry engaged in the transformation and amplification of nociceptive inputs to pain perception.

A Digital Health Intervention for Concussion: Development and Clinical Feasibility Study

BACKGROUND

Concussion is a common condition that can lead to a constellation of symptoms that affect quality of life, social integration, and return to work. There are several evidence-based behavioral and psychological interventions that have been found to improve postconcussion symptom burden. However, these are not routinely delivered, and individuals receive limited support during their concussion recovery.

OBJECTIVE

This study aimed to develop and test the feasibility of a digital health intervention using a systematic evidence-, theory-, and person-based approach.

METHODS

This was a mixed methodology study involving a scoping review (n=21), behavioral analysis, and logic model to inform the intervention design and content. During development, the intervention was optimized with feedback from individuals who had experienced concussions (n=12) and health care professionals (n=11). The intervention was then offered to patients presenting to the emergency department with a concussion (n=50). Participants used the intervention freely and input symptom data as part of the program. A number of outcome measures were obtained, including participant engagement with the intervention, postconcussion symptom burden, and attitudes toward the intervention. A selection of participants (n=15) took part in in-depth qualitative interviews to understand their attitudes toward the intervention and how to improve it.

RESULTS

Engagement with the intervention functionality was 90% (45/50) for the symptom diary, 62% (31/50) for sleep time setting, 56% (28/50) for the alcohol tracker, 48% (24/50) for exercise day setting, 34% (17/50) for the thought diary, and 32% (16/50) for the goal setter. Metrics indicated high levels of early engagement that trailed off throughout the course of the intervention, with an average daily completion rate of the symptom diary of 28.23% (494/1750). A quarter of the study participants (13/50, 26%) were classified as high engagers who interacted with all the functionalities within the intervention. Quantitative and qualitative feedback indicated a high level of usability and positive perception of the intervention. Daily symptom diaries (n=494) demonstrated a wide variation in individual participant symptom burden but a decline in average burden over time. For participants with Rivermead scores on completion of HeadOn, there was a strong positive correlation (r=0.86; P<.001) between their average daily HeadOn symptom diary score and their end-of-program Rivermead score. Insights from the interviews were then fed back into development to optimize the intervention and facilitate engagement.

CONCLUSIONS

Using this systematic approach, we developed a digital health intervention for individuals who have experienced a concussion that is designed to facilitate positive behavior change. Symptom data input as part of the intervention provided insights into postconcussion symptom burden and recovery trajectories.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05069948; https://clinicaltrials.gov/ct2/show/NCT05069948.

Why are patients with acute traumatic brain injury not routinely assessed or treated for vestibular dysfunction in the UK? A qualitative study

OBJECTIVES

Vestibular dysfunction is common in patients with acute traumatic brain injury (aTBI). Persisting vestibular symptoms (ie, dizziness and imbalance) are linked to poor physical, psychological and socioeconomic outcomes. However, routine management of vestibular dysfunction in aTBI is not always standard practice. We aimed to identify and explore any healthcare professional barriers or facilitators to managing vestibular dysfunction in aTBI.

DESIGN

A qualitative approach was used. Data were collected using face to face, semi-structured interviews and analysed using the Framework approach.

SETTING

Two major trauma centres in London, UK.

PARTICIPANTS

28 healthcare professionals participated: 11 occupational therapists, 8 physiotherapists and 9 surgical/trauma doctors.

RESULTS

Vestibular assessment and treatment were not routinely undertaken by trauma ward staff. Uncertainty regarding responsibility for vestibular management on the trauma ward was perceived to lead to gaps in patient care. Interestingly, the term dizziness was sometimes perceived as an 'invisible' and vague phenomenon, leading to difficulties identifying or 'proving' dizziness and a tendency for making non-specific diagnoses. Barriers to routine assessment and treatment included limited knowledge and skills, a lack of local or national guidelines, insufficient training and concerns regarding the practical aspects of managing vestibular dysfunction. Of current trauma ward staff, therapists were identified as appropriate healthcare professionals to adopt new behaviours regarding management of a common form of vestibular dysfunction (benign paroxysmal positional vertigo). Strategies to support this behaviour change include heightened clarity around role, implementation of local or national guidelines, improved access to training and multidisciplinary support from experts in vestibular dysfunction.

CONCLUSIONS

This study has highlighted that role and knowledge barriers exist to multidisciplinary management of vestibular dysfunction in aTBI. Trauma ward therapists were identified as the most appropriate healthcare professionals to adopt new behaviours. Several strategies are proposed to facilitate such behaviour change.

TRIAL REGISTRATION NUMBER

ISRCTN91943864.

Multidimensional pain phenotypes after Traumatic Brain Injury

More than 50% of individuals develop chronic pain following traumatic brain injury (TBI). Research suggests that a significant portion of post-TBI chronic pain conditions is neuropathic in nature, yet the relationship between neuropathic pain, psychological distress, and somatosensory function following TBI is not fully understood. This study evaluated neuropathic pain symptoms, psychological and somatosensory function, and psychosocial factors in individuals with TBI (TBI, N = 38). A two-step cluster analysis was used to identify phenotypes based on the Neuropathic Pain Symptom Inventory and Beck's Anxiety Inventory scores. Phenotypes were then compared on pain characteristics, psychological and somatosensory function, and psychosocial factors. Our analyses resulted in two different neuropathic pain phenotypes: (1) Moderate neuropathic pain severity and anxiety scores (MNP-AS, N = 11); and (2) mild or no neuropathic pain symptoms and anxiety scores (LNP-AS, N = 27). Furthermore, the MNP-AS group exhibited greater depression, PTSD, pain severity, and affective distress scores than the LNP-AS group. In addition, thermal somatosensory function (difference between thermal pain and perception thresholds) was significantly lower in the MNP-AS compared to the LNP-AS group. Our findings suggest that neuropathic pain symptoms are relatively common after TBI and are not only associated with greater psychosocial distress but also with abnormal function of central pain processing pathways.

Relationship between Dizziness and the Core Vestibular Projection Injury in Patients with Mild Traumatic Brain Injury

Some studies have reported that a core vestibular projection (CVP) injury is associated with dizziness following a brain injury using diffusion tensor tractography (DTT). On the other hand, there has been no DTT study on dizziness caused by a CVP injury in patients with mild traumatic brain injury (TBI). In this study, DTT was used to examine the relationship between dizziness and CVP injury in patients with mild TBI. Forty-three patients with mild TBI and twenty-nine normal subjects were recruited. The patients were classified into two groups based on the dizziness score: group A, patients with a dizziness score less than 2 on the sub-item score for dizziness in the Rivermead Post-concussion Symptoms Questionnaire; group B, patients with a dizziness score above 2. The tract volume (TV) in group B was significantly lower than group A and the control group (p < 0.05). By contrast, the TV in group A was similar to the control group (p > 0.05). Regarding the correlation, the dizziness score of all patients showed a strong negative correlation with the TV of the CVP (r = −0.711, p < 0.05). DTT revealed the CVP injury in patients with dizziness after mild TBI. In addition, the severity of dizziness of these patients was closely related to the injury severity of the CVP.

Nonpharmacological Treatment of Persistent Postconcussion Symptoms in Adults: A Systematic Review and Meta-analysis and Guideline Recommendation

IMPORTANCE

Persistent (>4 weeks) postconcussion symptoms (PPCS) are challenging for both patients and clinicians. There is uncertainty about the effect of commonly applied nonpharmacological treatments for the management of PPCS.

OBJECTIVE

To systematically assess and summarize evidence for outcomes related to 7 nonpharmacological interventions for PPCS in adults (aged >18 years) and provide recommendations for clinical practice.

DATA SOURCES

Systematic literature searches were performed via Embase, MEDLINE, PsycINFO, CINAHL, PEDro, OTseeker, and Cochrane Reviews (via MEDLINE and Embase) from earliest possible publication year to March 3, 2020. The literature was searched for prior systematic reviews and primary studies. To be included, studies had to be intervention studies with a control group and focus on PPCS.

STUDY SELECTION

A multidisciplinary guideline panel selected interventions based on frequency of use and need for decision support among clinicians, including early information and advice, graded physical exercise, vestibular rehabilitation, manual treatment of neck and back, oculomotor vision treatment, psychological treatment, and interdisciplinary coordinated rehabilitative treatment. To be included, studies had to be intervention studies within the areas of the predefined clinical questions, include a control group, and focus on symptoms after concussion or mild traumatic brain injury.

DATA EXTRACTION AND SYNTHESIS

Extraction was performed independently by multiple observers. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used for data abstraction and data quality assessment. Included studies were assessed using the Assessment of Multiple Systematic Reviews (AMSTAR) tool and the Cochrane Risk of Bias (randomized clinical trials) tool. Meta-analysis was performed for all interventions where possible. Random-effects models were used to calculate pooled estimates of effects. The level and certainty of evidence was rated and recommendations formulated according to the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework.

MAIN OUTCOMES AND MEASURES

All outcomes were planned before data collection began according to a specified protocol. The primary outcomes were the collective burden of PPCS and another outcome reflecting the focus of a particular intervention (eg, physical functioning after graded exercise intervention).

RESULTS

Eleven systematic reviews were identified but did not contribute any primary studies; 19 randomized clinical trials comprising 2007 participants (1064 women [53.0%]) were separately identified and included. Evidence for the 7 interventions ranged from no evidence meeting the inclusion criteria to very low and low levels of evidence. Recommendations were weak for early information and advice, graded physical exercise, vestibular rehabilitation, manual treatment of the neck and back, psychological treatment, and interdisciplinary coordinated rehabilitative treatment. No relevant evidence was identified for oculomotor vision treatment, so the panel provided a good clinical practice recommendation based on consensus.

CONCLUSIONS AND RELEVANCE

Based on very low to low certainty of evidence or based on consensus, the guideline panel found weak scientific support for commonly applied nonpharmacological interventions to treat PPCS. Results align with recommendations in international guidelines. Intensified research into all types of intervention for PPCS is needed.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Mild traumatic brain injury affects the features of migraine

BACKGROUND

Headache is one of the most common symptoms after concussion, and mild traumatic brain injury (mTBI) is a risk factor for chronic migraine (CM). However, there remains a paucity of data regarding the impact of mTBI on migraine-related symptoms and clinical course.

METHODS

Of 2161 migraine patients who participated in the American Registry for Migraine Research between February 2016 and March 2020, 1098 completed questions assessing history of TBI (50.8%). Forty-four patients reported a history of moderate to severe TBI, 413 patients reported a history of mTBI. Patients' demographics, headache symptoms and triggers, history of physical abuse, allodynia symptoms (ASC-12), migraine disability (MIDAS), depression (PHQ-2), and anxiety (GAD-7) were compared between migraine groups with (n = 413) and without (n = 641) a history of mTBI. Either the chi-square-test or Fisher's exact test, as appropriate, was used for the analyses of categorical variables. The Mann-Whitney test was used for the analyses of continuous variables. Logistic regression models were used to compare variables of interest while adjusting for age, gender, and CM.

RESULTS

A significantly higher proportion of patients with mTBI had CM (74.3% [307/413] vs. 65.8% [422/641], P = 0.004), had never been married or were divorced (36.6% [147/402] vs. 29.4% [187/636], P = 0.007), self-reported a history of physical abuse (24.3% [84/345] vs. 14.3% [70/491], P <  0.001), had mild to severe anxiety (50.5% [205/406] vs. 41.0% [258/630], P = 0.003), had headache-related vertigo (23.0% [95/413] vs. 15.9% [102/640], P = 0.009), and difficulty finding words (43.0% [174/405] vs. 32.9% [208/633], P <  0.001) in more than half their attacks, and headaches triggered by lack of sleep (39.4% [155/393] vs. 32.6% [198/607], P = 0.018) and reading (6.6% [26/393] vs. 3.0% [18/607], P = 0.016), compared to patients without mTBI. Patients with mTBI had significantly greater ASC-12 scores (median [interquartile range]; 5 [1-9] vs. 4 [1-7], P < 0.001), MIDAS scores (42 [18-85] vs. 34.5 [15-72], P = 0.034), and PHQ-2 scores (1 [0-2] vs. 1 [0-2], P = 0.012).

CONCLUSION

Patients with a history of mTBI are more likely to have a self-reported a history of physical abuse, vertigo, and allodynia during headache attacks, headaches triggered by lack of sleep and reading, greater headache burden and headache disability, and symptoms of anxiety and depression. This study suggests that a history of mTBI is associated with the phenotype, burden, clinical course, and associated comorbid diseases in patients with migraine, and highlights the importance of inquiring about a lifetime history of mTBI in patients being evaluated for migraine.

Factors influencing clinical symptoms and treatment of patients with traffic accident injuries: A retrospective chart review with a questionnaire survey

This study analyzed factors influencing clinical symptoms and treatment of patients with traffic accident injuries. It used a retrospective chart review and questionnaire survey obtained from 560 patients (266 men and 294 women). It also conducted follow-up observations of progress after car insurance settlements and investigated the usefulness of and patient satisfaction with integrative Korean medicine treatment for traffic accident injuries. Retrospective data of patients admitted for traffic accident injury were obtained. A questionnaire survey was conducted to collect data regarding the degree of traffic accident damage, severity of pain at settlement, any treatment after settlement and duration and cost of such treatment, and patient satisfaction with car insurance services and Korean medicine treatment for traffic accident injury. The results showed no significant association between pain and the degree of damage to the car at the time of traffic accident (P = 0.662), although the degree of damage to the car was more significantly associated with time to reach a car insurance settlement than severity of pain in the patient (P = 0.003). There was no significant association between the degree of damage to the car in a traffic accident and pain after a traffic accident. Greater severity of pain at the time of the car insurance settlement was associated with greater cost and longer time spent in treatment after the car insurance settlement.

Head- and neck-related symptoms post-motor vehicle collision (MVC): Separate entities or two-sides of the same coin?

BACKGROUND AND AIM

Although post-motor vehicle collision (MVC) pain and symptoms are largely convergent among those with mild traumatic brain injury (mTBI) and whiplash associated disorder (WAD), and patients oftentimes report initial neck and head complaints, the clinical picture of mTBI and WAD has been primarily studied as separate conditions which may result in an incomplete clinical picture. As such, this study was conducted to explore the role of pain and post-traumatic psychological features in explaining both head and neck-related symptom variability in a cohort of post-collision patients. This is with the goal of disentangling if contributory factors are uniquely related to each diagnosis, or are shared between the two.

METHODS

Patients recruited in the very early acute phase (<72 h) returned for clinical and psychological assessment at 6 months post-accident. In order to determine which factors were unique and which ones were overlapping the same potential contributors: mean head pain, mean neck pain, female gender, number of post-collision painful body areas, PTSD, and depression were included in the regression models for both neck disability index (NDI) and Rivermead post-concussion symptoms questionnaire (RPQ).

RESULTS

Of 223 recruited participants, 70 returned for a follow-up visit (age range 18-64, mean(SD) 37.6 (11.9), 29F). This cohort primarily met the criteria for mTBI, but also fulfilled the criteria for whiplash, reinforcing the duality of injury presentation. Correlations existed between the NDI and RPQ scores (Spearman's ρ=0.66, p<0.001), however overlap was only partial. Regression analysis showed that after the removal of area-of-injury pain neck related disability (r = 0.80, p <0.001) was explained solely by number of painful body areas (ß=0.52, p <0.001). In contrast, post-concussion syndrome symptoms (r = 0.86, p<0.001) are influenced by clinical pain, painful body areas (ß=0.31, p = 0.0026), female gender (ß=0.19, p = 0.0053), and psychological factors of depression (ß=0.31, p = 0.0028) and PTSD symptoms (ß=0.36, p = 0.0013).

CONCLUSIONS

It seems that while mechanisms of neck- and head-related symptoms in post-collision patients do share a common explanatory feature, of residual body pain, they are not entirely overlapping. In that psychological factors influence post-concussion syndrome symptoms, but not post-whiplash neck disability.

Patients with mild traumatic brain injury and acute neck pain at the emergency department are a distinct category within the mTBI spectrum: a prospective multicentre cohort study

BACKGROUND

Acute neck pain (ANP) has recently been demonstrated to be a predictor of persistent posttraumatic complaints after mild traumatic brain injury (mTBI). The aim of this study was to determine specific characteristics of patients with ANP following mTBI, their posttraumatic complaints and relationship with functional outcome.

METHODS

Data from a prospective follow-up study of 922 mTBI patients admitted to the emergency department (ED) in three level-one trauma centres were analysed. Patients were divided into two groups: 156 ANP patients and 766 no acute neck pain (nANP) patients. Posttraumatic complaints were evaluated 2 weeks and 6 months post-injury using standardized questionnaires and functional outcome was evaluated at 6 months with the Glasgow Outcome Scale Extended (GOSE).

RESULTS

ANP patients were more often female (p < 0.01), younger (38 vs. 47 years, p < 0.01) with more associated acute symptoms at the ED (p < 0.05) compared to nANP patients. More motor vehicle accidents (12% vs. 6%, p = 0.01) and less head wounds (58% vs. 73%, p < 0.01) in ANP patients indicated 'high-energy low-impact' trauma mechanisms. ANP patients showed more posttraumatic complaints 2 weeks and 6 months post-injury (p < 0.05) and more often incomplete recovery (GOSE < 8) was present after 6 months (56% vs. 40%, p = 0.01).

CONCLUSIONS

MTBI patients with acute neck pain at the ED constitute a distinct group within the mTBI spectrum with specific injury and demographic characteristics. Early identification of this at risk group already at the ED might allow specific and timely treatment to avoid development of incomplete recovery.

Persistent Postconcussion Symptoms: An Expert Consensus-Based Definition Using the Delphi Method

OBJECTIVE

To provide an expert consensus definition of persistent postconcussion symptoms following a mild traumatic brain injury (mTBI).

PARTICIPANTS

Canadian healthcare professionals caring for patients with mTBI.

DESIGN

Online Delphi process.

MAIN MEASURES

A first Delphi round documented important dimensions or criteria to consider when defining persistent symptoms. Expert opinions were then resubmitted in 4 subsequent Delphi rounds and their relevance was rated using a 9-point Likert scale. An item with a median rating of 7 or more and a sufficient level of agreement were considered consensual.

RESULTS

After 5 rounds, consensus was reached on a set of criteria that can be summarized as follows: presence of any symptom that cannot be attributed to a preexisting condition and that appeared within hours of an mTBI, that is still present every day 3 months after the trauma, and that has an impact on at least one sphere of a person's life.

CONCLUSION

This Delphi consensus proposes a set of criteria that support a more uniform definition of persistent symptoms in mild TBI among clinicians and researchers. This definition may help clinicians better identify persistent postconcussion symptoms and improve patient management.

Rating of pre-injury symptoms over time in patients with mild traumatic brain injury: the good-old-days bias revisited

OBJECTIVE

Post-concussion syndrome (PCS) occurs following mild traumatic brain injury (mTBI). Patients with mTBI are often assessed using self-report instruments that rely on perception of current symptoms compared to how they felt and functioned pre-injury. The objective was to examine reliability of patients' post-injury reporting of their pre-injury symptoms.

METHODS

We included two control groups (trauma patients without brain injury history and healthy controls) who were recruited at an outpatient surgical clinic and among the working and social environment of the researchers, respectively. The Head Injury Symptom Checklist (HISC) was used to assess pre-injury and current symptoms at four time points post injury. We included 836 patients with mTBIs, 191 trauma patients without brain injury history, and 100 healthy controls.

RESULTS

Patients with mTBI reported significantly more pre-injury symptoms than both control groups (p < .001). Forty-five percent of patients with mTBI were inconsistent in their pre-injury ratings across four assessments. Patients with post-injury PCS reported much greater pre-injury symptoms and were more often inconsistent.

CONCLUSION

Accurately assessing PCS by comparing pre with post-injury complaints is difficult, and may have implications for diagnosis when using self-report instruments. Therefore, post-injury PCS diagnosis should be interpreted with caution and PCS should ideally be examined using clinical examination.

Mild traumatic brain injury/concussion and female sexuality, a scoping review of the literature

Background

The American Congress of Rehabilitation Medicine (ACRM) in 2010 called for more head injury research on gender disparities to bridge the gender gap for the short-and long-term effects of TBI, including sexual and reproductive outcomes. In this paper, we review the state of the literature before and after the ACRM announcement, and evaluate how research teams have considered females and mildly injured TBI(mTBI)/concussion groups in post-TBI-related changes in sexual functioning.

Methods

The research question for this scoping review was “what is the state of the literature in the evaluation of post-TBI sexual changes for women, and individuals with mTBI?” Using the 2010 ACRM call for action as a line of demarcation, we compared our findings before and after the 2010 announcement.

Results

We identified 9 research studies that addressed sexual functioning changes in females and mTBI/concussion groups. Four of the nine were published before the 2010 ACRM announcement, and five were published after. The representation of female research participants increased steadily over the 28-year timespan. The proportion of individuals with mTBI included in the post-2010 era was higher than the earlier time period. Consistently, women with mTBI reported more adverse sexual outcomes compared to male cohorts, orthopaedic, and non-injured comparison groups. This observation persisted regardless of recruitment site (rehabilitation center/Emergency Department (ED)/Community) or time of outcome assessment (acute versus chronic). The findings also remained despite the heterogeneity of survey questionnaires used to evaluate sexual functioning outcomes. Excluding the most recent 2019 study, none of the research groups compared the findings by TBI severity, making it difficult to fully understand how concussion-related sexual changes compare to more severe forms of the head injury. The long term impacts of the sexual changes, such as infertility and relationship discord were also absent across all studies; even though most evaluated outcomes chronically (some as far out as 20 years post injury).

Conclusion

The number of publications in the era before the ACRM call for action and afterwards were almost identical. In order to tailor interventions for the appropriate groups of TBI patients, more neurosexuality research is needed to increase awareness of the importance of sexuality as a health outcome for individuals with neurodisabilities.

Frequency of Primary Neck Pain in Mild Traumatic Brain Injury/Concussion Patients

OBJECTIVES

To determine (1) the frequency of neck pain overall and relative to other symptoms in patients presenting to a level I trauma center emergency department (ED) with mild traumatic brain injury (mTBI) and (2) the predictors of primary neck pain in this population.

DESIGN

Cohort study.

SETTING

Level I trauma center ED.

PARTICIPANTS

Patients presenting to the ED with symptoms of mTBI having been exposed to an event that could have caused mTBI (N=95).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Frequency of self-reported neck pain as measured by Sport Concussion Assessment Tool 3 (SCAT3) symptom questionnaire at <3, 8, 15, and 45 days post injury. Primary neck pain was defined in 2 ways: (1) neck pain rated as equal or greater in severity than all other SCAT3 symptoms and (2) neck pain worse than all other symptoms.

RESULTS

The frequency of any reported neck pain was 68.4%, 50.6%, 49%, and 41.9% within 72 hours and at 8, 15, and 45 days, respectively. Frequency of primary neck pain (equal or worse/worse definitions) was 35.8%/17.9%, 34.9%/14.5%, 37%/14.8%, and 39.2%/10.8% across the 4 follow-up assessments. Participants who sustained their injuries in motor vehicle collisions had a higher rate of primary neck pain than those with other mechanisms of injury.

CONCLUSIONS

A sizable percentage of patients who present to level I trauma center EDs with mTBI report neck pain, which is commonly rated as similar to or worse than other mTBI-related symptoms. Primary neck pain is more common after motor vehicle collisions than with other mechanisms of injury. These findings support consensus statements identifying cervical injury as an important potential concurrent diagnosis in patients with mTBI.

Can the Neck Contribute to Persistent Symptoms Post Concussion? A Prospective Descriptive Case Series

BACKGROUND

Persistent symptoms post concussion can arise from a range of sources, including the neck. There is little description of neck assessment findings in people with persistent symptoms post concussion.

OBJECTIVES

To assess people with persistent symptoms following a concussion and determine whether the neck has also been injured, and to evaluate the potential of the neck to contribute to their symptoms.

METHODS

A consecutive series of participants (n = 20) referred for neck assessment were prospectively recruited by 2 providers of a multidisciplinary concussion service for people with persistent symptoms. Data were collected at initial assessment and on completion of neck treatment, which included standard questionnaires (Rivermead Post Concussion Symptoms Questionnaire, Neck Disability Index, Dizziness Handicap Inventory); patient-reported measures of headache, dizziness, and neck pain; physical examination findings; and details of comorbidities.

RESULTS

Participants were evaluated at a mean of 7.5 weeks post concussion (median, 5 weeks). On neck assessment, 90% were considered by the clinician to have a neck problem contributing to their current symptoms. Multiple findings were consistent with this view, including moderate-to-severe Neck Disability Index scores (mean ± SD, 33.4 ± 9.5 points), frequent neck pain (85%), frequent moderate-to-severe pain on occiput-C4 segmental assessment (85%), a positive flexion-rotation test (45%), and muscle tenderness (50%-55%).

CONCLUSION

Multiple findings were indicative of concurrent neck injury, particularly involving the upper cervical spine. These neck-related findings are important to recognize, as they have the potential to contribute to persistent symptoms post concussion and may respond to neck treatment. This study was prospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12616001183471). J Orthop Sports Phys Ther 2019;49(11):845-854. Epub 1 Jun 2019. doi:10.2519/jospt.2019.8547.

Brain Drain: Psychosocial Factors Influence Recovery Following Mild Traumatic Brain Injury-3 Recommendations for Clinicians Assessing Psychosocial Factors

Mild traumatic brain injury is a major global public health concern. While most people recover within days to months, 1 in 5 people with mild traumatic brain injury report persistent, disabling symptoms that interfere with participation in work, school, and sport. People with injuries to regions other than the head may report similar symptoms. The biopsychosocial model of health explains this phenomenon in terms of factors associated with recovery that are not biomedical. Important psychosocial factors include poor recovery expectations and pretraumatic and posttraumatic psychological symptoms. Recent clinical practice guidelines recommend that clinicians examine all relevant biopsychosocial factors that may contribute to persistent postconcussive symptoms and consider them when helping their patients make health-management decisions. However, because clinical training continues to prioritize biomedical symptoms, clinicians may not feel confident in the psychosocial domain. Our objective is to provide 3 recommendations for clinicians to assess psychosocial factors in patients after concussion, and to argue a case for clinicians to improve their skills in assessing psychosocial factors. J Orthop Sports Phys Ther 2019;49(11):842-844. Epub 1 Jun 2019. doi:10.2519/jospt.2019.8849.

Randomised controlled clinical trial of a structured cognitive rehabilitation in patients with attention deficit following mild traumatic brain injury: study protocol

OBJECTIVES

To measure the clinical, structural and functional changes of an individualised structured cognitive rehabilitation in mild traumatic brain injury (mTBI) population.

SETTING

A single centre study, Malaysia.

PARTICIPANTS

Adults aged between 18 and 60 years with mTBI as a result of road traffic accident, with no previous history of head trauma, minimum of 9 years education and abnormal cognition at 3 months will be included. The exclusion criteria include pre-existing chronic illness or neurological/psychiatric condition, long-term medication that affects cognitive/psychological status, clinical evidence of substance intoxication at the time of injury and major polytrauma. Based on multiple estimated calculations, the minimum intended sample size is 50 participants (Cohen's d effect size=0.35; alpha level of 0.05; 85% power to detect statistical significance; 40% attrition rate).

INTERVENTIONS

Intervention group will receive individualised structured cognitive rehabilitation. Control group will receive the best patient-centred care for attention disorders. Therapy frequency for both groups will be 1 hour per week for 12 weeks.

OUTCOME MEASURES

Primary: Neuropsychological Assessment Battery-Screening Module (S-NAB) scores. Secondary: Diffusion Tensor Imaging (DTI) parameters and Goal Attainment Scaling score (GAS).

RESULTS

Results will include descriptive statistics of population demographics, CogniPlus cognitive program and metacognitive strategies. The effect of intervention will be the effect size of S-NAB scores and mean GAS T scores. DTI parameters will be compared between groups via repeated measure analysis. Correlation analysis of outcome measures will be calculated using Pearson's correlation coefficient.

CONCLUSION

This is a complex clinical intervention with multiple outcome measures to provide a comprehensive evidence-based treatment model.

ETHICS AND DISSEMINATION

The study protocol was approved by the Medical Research Ethics Committee UMMC (MREC ID NO: 2016928-4293). The findings of the trial will be disseminated through peer-reviewed journals and scientific conferences.

TRIAL REGISTRATION NUMBER

NCT03237676.

Validity and reliability of the Neuropsychological Assessment Battery - Screening Module (S-NAB) in a subset of Malaysian population with mild traumatic brain injury (mTBI)

This study assessed the validity (construct validity) and reliability (internal consistency) of the Neuropsychological Assessment Battery Screening Module (S-NAB) in detecting mild cognitive deficit/alteration in multicultural, multilingual, and multiethnic mild traumatic brain injury (mTBI) population of Malaysia. S-NAB and Montreal Cognitive Assessment (MoCA) data from 114 patients with mTBI (93 males; 21 females) aged 18 to 60 years old were obtained at University Malaya Medical Center, Malaysia. The mean age was 28.17 ± 8.57 years and mean education years was 12.40 ± 2.01. Convergent validity was assessed between S-NAB domain scores and MoCA total scores by using Pearson's correlation and internal consistency was assessed using Cronbach's alpha. Acceptable internal consistency (α ≥ .70) was found for Attention, Language, and Memory domains but weak internal consistencies (α < .50) were found for Spatial and Executive Function domains. There were positive but weak correlations between S-NAB and MoCA. These findings provide some support for the application of S-NAB in assessing mild cognitive deficits of mTBI population in a Malaysian setting.

Psychophysic-psychological dichotomy in very early acute mTBI pain: A prospective study

OBJECTIVE

To characterize the pain-related somatosensory and psychological presentation of very early acute patients with a mild traumatic brain injury (mTBI).

METHODS

Patients with an mTBI participated in a prospective observational study undergoing clinical, psychophysic, and psychological assessment within 72 hours after the accident. Healthy controls underwent similar protocol.

RESULTS

One hundred acute patients with an mTBI (age 36 ± 12.5 [SD] years, range 19-67 years, 42 women) and 80 healthy controls (age 43 ± 14.3 years, range 24-74 years, 40 women) participated. Patients with an mTBI demonstrated a pronociceptive psychophysic response in most tests such as less efficient pressure-pain threshold-conditioned pain modulation (0.19 ±0.19±.09 vs. 0.91±.10 kg, p < 0.001) and lower temperature needed to elicit a Pain50 response (44.72 ± 0.26°C vs 46.41 ± 0.30°C, p < 0.001). Their psychophysic findings correlated with clinical pain measures, e.g., Pain50 temperature and mean head (r = -0.21, p = 0.045) and neck (r = -0.26, p = 0.011) pain. The pain-catastrophizing magnification subscale was the only psychological variable to show a difference from the controls, while no significant correlations were found between any psychological measures and the clinical or psychophysic pain measures.

CONCLUSIONS

There appears to be a dichotomy between somatosensory and psychological findings in the very early acute post-mTBI stage; while the first is altered and is associated with the clinical picture, the second is unchanged. In the context of the ongoing debate on the pathophysiologic nature of the post-mTBI syndrome, our findings support its "physical" basis, free of mental influence, at least in the short time window after the injury.

Survey of chiropractic clinicians on self-reported knowledge and recognition of concussion injuries

Background

There has been little study of the recognition of mild traumatic brain injury (MTBI) by the chiropractic practitioner, or of the inquiry by the clinician to assess those patients who may be suffering from the condition, but fail to report the symptoms. Although severe cases of TBI are more often recognized and treated by attendance to hospital or emergency room, MTBI is less recognizable and would present a long-term risk to the patient. Given the clinical risk associated with failure to recognize such injuries, training of the clinician in the subtle signs of MTBI is imperative. What we currently know about training in the recognition of MTBI is from limited recent knowledge based studies. This study is intended to assess the self-reported mild traumatic brain injury (MTBI) knowledge, recognition and treatment by chiropractic practitioners.

Methods

A previously published standardized set of survey items was distributed to a captive audience of chiropractic practitioners at the July 2016 Texas Chiropractic College annual symposium. The sample population was a convenience sample of chiropractic clinicians who were assessed for MTBI knowledge and common practices.

Results

There was a response rate of 43% of the 125 attendees. The survey demonstrated confidence in MTBI diagnosis. Average MTBI knowledge and recognition score was only 27% ± 22%. Frequency of MTBI patients presenting to the chiropractic clinician office was an average of less than one per month. Sixty nine percent (69%) of the clinicians relied upon their history and clinical exam for diagnosis. There was no knowledge of the Balance Error Scoring system and only 20% utilized the Standardized Concussion Assessment Tool (SCAT). The primary action of the chiropractic clinician who suspected MTBI was to refer to a neurological specialist (76%). A small minority of practitioners would provide treatment.

Conclusions

There is an overconfidence of the chiropractic practitioner in recognition of MTBI which is incongruent with the low knowledge scores. Further education of the chiropractic clinician is warranted.

Trial registration

University Hospital Medical Information Network Clinical Trials Registry. Retrospectively registered (UMIN-CTR), trial number: UMIN#000029744 (Receipt# R000033980) data: October 27, 2017.​Date of enrollment 7/14/2016.

Electronic supplementary material

The online version of this article (10.1186/s12998-018-0186-y) contains supplementary material, which is available to authorized users.

The schism in chiropractic through the eyes of a 1st year chiropractic student

Since its inception, the chiropractic profession has been divided along ideological fault lines. These divisions have led to a profession wide schism, which has limited mainstream acceptance, utilisation, social authority and integration. The authors explore the historical origins of this schism, taking time to consider historical context, religiosity, perpetuating factors, logical fallacies and siege mentality. Evidence is then provided for a way forward, based on the positioning of chiropractors as mainstream partners in health care.

Early Detection of Poor Outcome after Mild Traumatic Brain Injury: Predictive Factors Using a Multidimensional Approach a Pilot Study

Mild traumatic brain injury (MTBI) is a common condition within the general population, usually with good clinical outcome. However, in 10-25% of cases, a post-concussive syndrome (PCS) occurs. Identifying early prognostic factors for the development of PCS can ensure widespread clinical and economic benefits. The aim of this study was to demonstrate the potential value of a comprehensive neuropsychological evaluation to identify early prognostic factors following MTBI. We performed a multi-center open, prospective, longitudinal study that included 72 MTBI patients and 42 healthy volunteers matched for age, gender, and socioeconomic status. MTBI patients were evaluated 8-21 days after injury, and 6 months thereafter, with a full neurological and psychological examination and brain MRI. At 6 months follow-up, MTBI patients were categorized into two subgroups according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as having either favorable or unfavorable evolution (UE), corresponding to the presence of major or mild neurocognitive disorder due to traumatic brain injury. Univariate and multivariate logistical regression analysis demonstrated the importance of patient complaints, quality of life, and cognition in the outcome of MTBI patients, but only 6/23 UE patients were detected early via the multivariate logistic regression model. Using several variables from each of these three categories of variables, we built a model that assigns a score to each patient presuming the possibility of UE. Statistical analyses showed this last model to be reliable and sensitive, allowing early identification of patients at risk of developing PCS with 95.7% sensitivity and 77.6% specificity.

Dizziness-related disability following mild-moderate traumatic brain injury

OBJECTIVE

To investigate the associations between dizziness-related disability after mild- moderate Traumatic Brain Injury (TBI) and personal factors, injury-related factors and post-injury functioning using the International Classification of Functioning, Disability and Health (ICF) as a framework.

METHODS

Baseline assessments for a Randomised Controlled Trial (RCT) were obtained for 65 patients (mean age 39.2 years; SD 12.9 years; 70.8% women) who had dizziness and reduced balance 2-6 months after injury. The severity of the brain injury, physical and psychological self-reported symptoms and results from the performance based tests were used as independent variables. The main outcome measure (dependent variable) was the Dizziness Handicap Inventory (DHI).

RESULTS

Multivariate analyses showed that, the dizziness-related disability was predicted by pre-injury comorbidities (p ≤ 0.05) and was associated with self-reported vertigo symptoms (p < 0.001), reduced performance-based balance (p ≤ 0.05) and psychological distress (p ≤ 0.05). These factors accounted for 62% of the variance in DHI.

CONCLUSION

Dizziness and balance problems after mild-moderate TBI appear to be complex biopsychosocial phenomena. Assessments linked to the ICF domains of functioning might contribute to a broader understanding of the needs of these patients. Further, prospective clinical studies with non-dizzy control groups are needed to investigate dizziness-related disability after TBI.

Neuropsychology of traumatic brain injury: An expert overview

Traumatic brain injury (TBI) is a serious healthcare problem, and this report is a selective review of recent findings on the epidemiology, pathophysiology and neuropsychological impairments following TBI. Patients who survive moderate-to-severe TBI frequently suffer from a wide range of cognitive deficits and behavioral changes due to diffuse axonal injury. These deficits include slowed information-processing and impaired long-term memory, attention, working memory, executive function, social cognition and self-awareness. Mental fatigue is frequently also associated and can exacerbate the consequences of neuropsychological deficits. Personality and behavioral changes can include combinations of impulsivity and apathy. Even mild TBI raises specific problems: while most patients recover within a few weeks or months, a minority of patients may suffer from long-lasting symptoms (post-concussion syndrome). The pathophysiology of such persistent problems remains a subject of debate, but seems to be due to both injury-related and non-injury-related factors.

Survey of Primary Contact Medical and Chiropractic Clinicians on Self-Reported Knowledge and Recognition of Mild Traumatic Brain Injuries: A Pilot Study

OBJECTIVE

The purpose of this study was to assess the self-reported knowledge of concussion recognition and treatment with first-contact family medical and chiropractic practitioners by means of a pilot study of the need, construct validity, and feasibility for further investigation of mild traumatic brain injury (MTBI) knowledge base.

METHODS

Two hundred forty-eight practicing chiropractic and 120 medical physicians in the south and northeastern sections of the United States were contacted by e-mail, telephone, and postal mail to answer an 18-item survey on knowledge, diagnosis, and common practice with respect to traumatic brain injury patients. Descriptive analysis was used to assess common trends.

RESULTS

Twenty-three chiropractic and 11 medical primary care practitioners returned completed surveys, making this a low-power pilot study. The majority claimed confidence in diagnosis of MTBI, but a lack of knowledge of many of the assessment tools and the international guidelines. Chiropractic and medical clinicians revealed similar competencies and differing deficiencies. Both groups admitted infrequent diagnosis of MTBI in practice. There was recognition of major TBI signs, but lack of recognition or inquiry for subtle MTBI signs.

CONCLUSIONS

There is a need and feasibility for further study of the knowledge transfer to the chiropractic physician with a larger population. These findings correlate with similar medical practitioner studies, and may also support previous findings of underreporting of the prevalence of MTBI. The survey instrument appears to provide valid data on knowledge of MTBIs, with some modifications.

New vignettes for the experimental manipulation of injury cause in prospective mild traumatic brain injury research

PURPOSE

This study developed standardized vignettes that depict a mild traumatic brain injury (TBI) from one of several causes and subjected them to formal expert review.

METHOD

A base vignette was developed using the World Health Organization operational criteria for mild TBI. Eight specific causes (e.g. sport vs assault) were examined. A convenience sample of mild TBI experts with a discipline background of Neuropsychology from North America, Australasia and Europe (n = 21) used an online survey to evaluate the vignettes and rated the role of cause on outcome.

RESULTS

The vignette suite was rated as fitting the mild TBI WHO operational diagnostic criteria at least moderately well. When compared to other factors, cause was not rated as significantly contributing to outcome. When evaluated in isolation, approximately half of the sample rated cause as important or very important and at least two of three clinical outcomes were associated with a different cause.

DISCUSSION

The vignettes may be useful in experimental mild TBI research. They enable the injury parameters to be controlled so that the effects of cause can be isolated and examined empirically. Such studies should advance understanding of the role of this factor in mild TBI outcome.

Word Memory Test Predicts Recovery in Claimants With Work-Related Head Injury

OBJECTIVE

To investigate the predictive validity of the Word Memory Test (WMT), a verbal memory neuropsychological test developed as a performance validity measure to assess memory, effort, and performance consistency.

DESIGN

Cohort study with 1-year follow-up.

SETTING

Workers' compensation rehabilitation facility.

PARTICIPANTS

Participants included workers' compensation claimants with work-related head injury (N=188; mean age, 44y; 161 men [85.6%]).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Outcome measures for determining predictive validity included days to suspension of wage replacement benefits during the 1-year follow-up and work status at discharge in claimants undergoing rehabilitation. Analysis included multivariable Cox and logistic regression.

RESULTS

Better WMT performance was significantly but weakly correlated with younger age (r=-.30), documented brain abnormality (r=.28), and loss of consciousness at the time of injury (r=.25). Claimants with documented brain abnormalities on diagnostic imaging scans performed better (∼9%) on the WMT than those without brain abnormalities. The WMT predicted days receiving benefits (adjusted hazard ratio, 1.13; 95% confidence interval, 1.04-1.24) and work status outcome at program discharge (adjusted odds ratio, 1.62; 95% confidence interval, 1.13-2.34).

CONCLUSIONS

Our results provide evidence for the predictive validity of the WMT in workers' compensation claimants. Younger claimants and those with more severe brain injuries performed better on the WMT. It may be that financial incentives or other factors related to the compensation claim affected the performance.

Subacute Pain after Traumatic Brain Injury Is Associated with Lower Insular N-Acetylaspartate Concentrations

Persistent pain is experienced by more than 50% of persons who sustain a traumatic brain injury (TBI), and more than 30% experience significant pain as early as 6 weeks after injury. Although neuropathic pain is a common consequence after CNS injuries, little attention has been given to neuropathic pain symptoms after TBI. Magnetic resonance spectroscopy (MRS) studies in subjects with TBI show decreased brain concentrations of N-acetylaspartate (NAA), a marker of neuronal density and viability. Although decreased brain NAA has been associated with neuropathic pain associated with spinal cord injury (SCI) and diabetes, this relationship has not been examined after TBI. The primary purpose of this study was to test the hypothesis that lower NAA concentrations in brain areas involved in pain perception and modulation would be associated with greater severity of neuropathic pain symptoms. Participants with TBI underwent volumetric MRS, pain and psychosocial interviews. Cluster analysis of the Neuropathic Pain Symptom Inventory subscores resulted in two TBI subgroups: The Moderate Neuropathic Pain (n = 17; 37.8%), with significantly (p = 0.038) lower insular NAA than the Low or no Neuropathic Pain group (n = 28; 62.2%), or age- and sex-matched controls (n = 45; p < 0.001). A hierarchical linear regression analysis controlling for age, sex, and time post-TBI showed that pain severity was significantly (F = 11.0; p < 0.001) predicted by a combination of lower insular NAA/Creatine (p < 0.001), lower right insular gray matter fractional volume (p < 0.001), female sex (p = 0.005), and older age (p = 0.039). These findings suggest that neuronal dysfunction in brain areas involved in pain processing is associated with pain after TBI.

Fitness-to-drive after mild traumatic brain injury: mapping the time trajectory of recovery in the acute stages post injury

INTRODUCTION

Little is known about the trajectory of recovery in fitness-to-drive after mild traumatic brain injury (mTBI). This means that health-care professionals have limited evidence on which to base recommendations to this cohort about driving.

OBJECTIVE

To determine fitness-to-drive status of patients with a mTBI at 24h and two weeks post injury, and to summarise issues reported by this cohort about return to driving.

METHOD

Quasi-experimental case-control design. Two groups of participants were recruited: patients with a mTBI (n=60) and a control group with orthopaedic injuries (n=60). Both groups were assessed at 24h post injury on assessments of fitness-to-drive. Follow-up occurred at two weeks post injury to establish driver status.

MAIN MEASURES

Mini mental state examination, occupational therapy-drive home maze test (OT-DHMT), Road Law Road Craft Test, University of Queensland-Hazard Perception Test, and demographic/interview form collected at 24h and at two weeks.

RESULTS

At the 24h assessment, only the OT-DHMT showed a difference in scores between the two groups, with mTBI participants being significantly slower to complete the test (p=0.01). At the two week follow-up, only 26 of the 60 mTBI participants had returned to driving. Injury severity combined with scores from the 24h assessment predicted 31% of the variance in time taken to return to driving. Delayed return to driving was reported due to: "not feeling 100% right" (n=14, 23%), headaches and pain (n=12, 20%), and dizziness (n=5, 8%).

CONCLUSION

This research supports existing guidelines which suggest that patients with a mTBI should not to drive for 24h; however, further research is required to map factors which facilitate timely return to driving.

Summary of the findings of the International Collaboration on Mild Traumatic Brain Injury Prognosis

In 2004, the WHO Collaborating Centre for Neurotrauma, Prevention, Management and Rehabilitation Task Force published the first large systematic review and best evidence synthesis on the clinical course and prognosis for recovery after MTBI. Ten years later, the International Collaboration on Mild Traumatic Brain Injury Prognosis (ICoMP) formed to update the original WHO Task Force results. This summary review highlights important clinical findings from the full ICoMP results including the current evidence on the course and prognosis of recovery after MTBI in diverse patient populations (e.g., adults, athletes and children) and injury environments (e.g., motor vehicle collisions) as well as on the risk of long-term outcomes after MTBI, such as Parkinson's disease and dementia. Additional clinical areas of interest in MTBI are also discussed including the similarities between MTBI and other traumatic injuries and the risk of Second Impact Syndrome after sport concussion. Clinicians can use this information to help inform patients on the likely course of recovery after MTBI/concussion and guide better decision-making in the care of these patients.