Short-term sequelae of minor head injury (6 years experience of minor head injury clinic)

Dynamic Prevalence of and Factors Associated With Fatigue Following Traumatic Brain Injury: A Systematic Review and Meta-analysis of Observational Studies

OBJECTIVE

To implement a systematic review and meta-analysis to comprehensively synthesize the prevalence of and factors associated with fatigue following traumatic brain injury (TBI).

METHODS

We systematically searched the PubMed, EMBASE, Cochrane Library, Cumulated Index to Nursing and Allied Health Literature, PsycINFO, and ProQuest Dissertations and Theses A&I databases in all fields from their inception to March 31, 2021. We included observational studies investigating fatigue at specific time points following TBI or factors associated with post-TBI fatigue. All data were analyzed using a random-effects model.

RESULTS

This meta-analysis included 29 studies that involved 12 662 patients with TBI and estimated the prevalence of post-TBI fatigue (mean age = 41.09 years); the meta-analysis also included 23 studies that involved 6681 patients (mean age = 39.95 years) and investigated factors associated with post-TBI fatigue. In patients with mild-to-severe TBI, the fatigue prevalence rates at 2 weeks or less, 1 to 3 months, 6 months, 1 year, and 2 years or more after TBI were 52.2%, 34.6%, 36.0%, 36.1%, and 48.8%, respectively. Depression (r = 0.48), anxiety (r = 0.49), sleep disturbance (r = 0.57), and pain (r = 0.46) were significantly associated with post-TBI fatigue. No publication bias was identified among the studies, except for those assessing fatigue prevalence at 6 months after TBI.

CONCLUSION

The pooled prevalence rates of post-TBI fatigue exhibited a U-shaped pattern, with the lowest prevalence rates occurring at 1 to 3 months after TBI. Depression, anxiety, sleep disturbance, and pain were associated with post-TBI fatigue. Younger patients and male patients were more likely to experience post-TBI fatigue. Our findings can assist healthcare providers with identifying appropriate and effective interventions targeting post-TBI fatigue at specific periods.

Traumatic Brain Injury, Sleep, and Melatonin-Intrinsic Changes with Therapeutic Potential

Traumatic brain injury (TBI) is one of the most prevalent causes of morbidity in the United States and is associated with numerous chronic sequelae long after the point of injury. One of the most common long-term complaints in patients with TBI is sleep dysfunction. It is reported that alterations in melatonin follow TBI and may be linked with various sleep and circadian disorders directly (via cellular signaling) or indirectly (via free radicals and inflammatory signaling). Work over the past two decades has contributed to our understanding of the role of melatonin as a sleep regulator and neuroprotective anti-inflammatory agent. Although there is increasing interest in the treatment of insomnia following TBI, a lack of standardization and rigor in melatonin research has left behind a trail of non-generalizable data and ambiguous treatment recommendations. This narrative review describes the underlying biochemical properties of melatonin as they are relevant to TBI. We also discuss potential benefits and a path forward regarding the therapeutic management of TBI with melatonin treatment, including its role as a neuroprotectant, a somnogen, and a modulator of the circadian rhythm.

Acute Treatment with the M-Channel (Kv7, KCNQ) Opener Retigabine Reduces the Long-Term Effects of Repetitive Blast Traumatic Brain Injuries

We investigated whether pharmacological increase of "M-type" (KCNQ, Kv7) K + channel currents by the M-channel opener, retigabine (RTG), acutely after repetitive traumatic brain injuries (rTBIs), prevents or reduces their long-term detrimental effects. rTBIs were studied using a blast shock air wave mouse model. Animals were monitored by video and electroencephalogram (EEG) records for nine months after the last injury to assess the occurrence of post-traumatic seizures (PTS), post-traumatic epilepsy (PTE), sleep-wake cycle architecture alterations, and the power of the EEG signals. We evaluated the development of long-term changes in the brain associated with various neurodegenerative diseases in mice by examining transactive response DNA-binding protein 43 (TDP-43) expression and nerve fiber damage ~ 2 years after the rTBIs. We observed acute RTG treatment to reduce the duration of PTS and impair the development of PTE. Acute RTG treatment also prevented post-injury hypersomnia, nerve fiber damage, and cortical TDP-43 accumulation and translocation from the nucleus to the cytoplasm. Mice that developed PTE displayed impaired rapid eye movement (REM) sleep, and there were significant correlations between seizure duration and time spent in the different stages of the sleep-wake cycle. We observed acute RTG treatment to impair injury-induced reduction of age-related increase in gamma frequency power of the EGG, which has been suggested to be necessary for a healthy aged brain. The data show that RTG, administered acutely post-TBI, is a promising, novel therapeutic option to blunt/prevent several long-term effects of rTBIs. Furthermore, our results show a direct relationship between sleep architecture and PTE.

Hierarchical clustering of prolonged post-concussive symptoms after 12 months: symptom-centric analysis and association with functional impairments

BACKGROUND

Following a concussion, approximately 15% of individuals experience persistent symptoms that can lead to functional deficits. However, underlying symptom-clusters that persist beyond 12 months have not been adequately characterized, and their relevance to functional deficits are unclear. The aim of this study was to characterize the underlying clusters of prolonged post-concussive symptoms lasting more than 12 months, and to investigate their association with functional impairments.

METHODS

Although hierarchical clustering is ideally suited in evaluating subjective symptom severities, it has not been applied to the Rivermead Post-Concussion Questionnaire (RPQ). The RPQ and functional impairments questions were administered via a smartphone application to 445 individuals who self-reported prolonged post-concussive symptoms. Symptom-clusters were obtained using agglomerative hierarchical clustering, and their association with functional deficits were investigated with sensitivity analyses, and corrected for multiple comparisons.

RESULTS

Five symptom-clusters were identified: headache-related, sensitivity to light and sound, cognitive, mood-related, and sleep-fatigue. Individuals with more severe RPQ symptoms were more likely to report functional deficits (p < 0.0001). Whereas the headache and sensitivity clusters were associated with at most one impairment, at-least-mild sleeping difficulties and fatigue were associated with four, and moderate-to-severe cognitive difficulties with five (all p < 0.01).

CONCLUSIONS

Symptom-clusters may be clinically useful for functional outcome stratification for targeted rehabilitation therapies. Further studies are required to replicate these findings in other cohorts and questionnaires, and to ascertain the effects of symptomatic intervention on functional outcomes.

Sleep Disorders in Traumatic Brain Injury

SUMMARY

Sleep disorders are common after traumatic brain injury (TBI). This study will review the spectrum and proposed mechanisms of TBI-associated sleep disorders and discuss the clinical approach to diagnosis and management of them. Disordered and fragmented sleep with insomnia and daytime sleepiness is very common after TBI. Sleep disruption contributes to morbidity and neurocognitive and neurobehavioral deficits and prolongs the recovery phase after injury. Early recognition and correction of these problems may limit the secondary effects of TBI and improve patient outcomes. Evaluating sleep disorders in TBI should be an important component of TBI assessment and management. Finally, newer research techniques for early diagnosis, prognosis, and improved outcomes after TBI will also be addressed.

Bypassing TBI: Metabolic Surgery and the Link between Obesity and Traumatic Brain Injury-a Review

Obesity is a common outcome of traumatic brain injury (TBI) that exacerbates principal TBI symptom domains identified as common areas of post-TBI long-term dysfunction. Obesity is also associated with increased risk of later-life dementia and Alzheimer's disease. Patients with obesity and chronic TBI may be more vulnerable to long-term mental abnormalities. This review explores the question of whether weight loss induced by bariatric surgery could delay or perhaps even reverse the progression of mental deterioration. Bariatric surgery, with its induction of weight loss, remission of type 2 diabetes, and other expressions of the metabolic syndrome, improves metabolic efficiency, leads to reversal of brain lesions seen on imaging studies, and improves function. These observations suggest that metabolic/bariatric surgery may be a most effective therapy for TBI.

Regulation of Circadian Clock Genes on Sleep Disorders in Traumatic Brain Injury Patients

BACKGROUND

In patients with traumatic brain injury (TBI), whether sleep disorder is associated with disturbances in molecular rhythmicity is unclear. This study aimed to investigate the relationship between abnormal sleep and regulation by circadian rhythms in patients with TBI.

METHODS

We sampled buccal cells and human blood samples from patients with TBI diagnosed with sleep disorders and those with normal sleep and investigated differences in the expression levels of Clock, Per2, and Bmal1 between the 2 groups.

RESULTS

The expression peaks of Clock, Per2, and Bmal1 were at 12:00. There was a statistically significant difference between the sleep disorder group and the normal sleep group in the level of Clock mRNA expression (P = 0.0003 in oral mucosa and P < 0.0001 in mononuclear cells). There was no significant between-group difference in Bmal1 mRNA expression level (P = 0.1187 in oral mucosa and P = 0.2094 in mononuclear cells). There were significant between-group differences in Per2 mRNA expression levels at 12:00 (P = 0.0102 in oral mucosa and P = 0.0006 in mononuclear cells) and 18:00 (P = 0.0004 in oral mucosa and P = 0.0015 in mononuclear cells) but no significant difference at 24:00 (P = 0.7838 in oral mucosa and P = 0.2808 in mononuclear cells).

CONCLUSIONS

Abnormal expression levels of Per2, Clock, and Bmal1 were detected in patients with TBI-related sleep disorders. These novel findings demonstrate disturbances in the molecular clock in TBI patients and have important implications for our understanding of the aberrant rhythms reported in this disease.

Sleep disorders in traumatic brain injury

BACKGROUND

Sleep disorders play a significant role in the care of those with Traumatic Brain Injury (TBI).

OBJECTIVE

To provide a literature review on the interaction of sleep and circadian processes on those with TBI.

METHODS

A literature review was conducted on PubMed using the following key words and their combination: "Sleep Apnea", "Traumatic Brain Injury", "Circadian", "Parasomnia", "Insomnia", "Hypersomnia", "Narcolepsy", and "Restless Legs". We review the spectrum of traumatic brain injury associated sleep disorders and discuss clinical approaches to diagnosis and treatment.

RESULTS

Disordered sleep and wakefulness after TBI is common. Sleep disruption contributes to morbidity, such as the development of neurocognitive and neurobehavioral deficits, and prolongs the recovery phase after injury. Early recognition and correction of these problems may limit the secondary effects of traumatic brain injury and improve neuro recovery/patient outcomes.

CONCLUSIONS

A more focused approach to sleep health is appropriate when caring for those with TBI.

A systematic review and meta-analysis of sleep architecture and chronic traumatic brain injury

Sleep quality appears to be altered by traumatic brain injury (TBI). However, whether persistent post-injury changes in sleep architecture are present is unknown and relatively unexplored. We conducted a systematic review and meta-analysis to assess the extent to which chronic TBI (>6 months since injury) is characterized by changes to sleep architecture. We also explored the relationship between sleep architecture and TBI severity. In the fourteen included studies, sleep was assessed with at least one night of polysomnography in both chronic TBI participants and controls. Statistical analyses, performed using Comprehensive Meta-Analysis software, revealed that chronic TBI is characterized by relatively increased slow wave sleep (SWS). A meta-regression showed moderate-severe TBI is associated with elevated SWS, reduced stage 2, and reduced sleep efficiency. In contrast, mild TBI was not associated with any significant alteration of sleep architecture. The present findings are consistent with the hypothesis that increased SWS after moderate-severe TBI reflects post-injury cortical reorganization and restructuring. Suggestions for future research are discussed, including adoption of common data elements in future studies to facilitate cross-study comparability, reliability, and replicability, thereby increasing the likelihood that meaningful sleep (and other) biomarkers of TBI will be identified.

Does magnesium sulfate have a role in the management of severe traumatic brain injury in civilian and military populations? A systematic review and meta-analysis

INTRODUCTION

Traumatic brain injury (TBI) is a significant cause of combat morbidity. Currently, the medical management of TBI is limited to supportive critical care. Magnesium sulfate has been studied as a potentially beneficial therapeutic agent.

METHODS

A systematic review and meta-analysis was undertaken, examining the role of magnesium in the management of severe TBI in adults. The primary outcome of the study was all-cause mortality, with secondary outcomes of Glasgow Outcome Score (GOS) and GCS. EMBASE, MEDLINE, CINAHL, WHO Trial Registry and the Cochrane Library database were systematically searched, with data included until 1 February 2017. Inclusion criteria were: human study; aged >13 years; randomised controlled trial; severe TBI. Exclusion criteria were: data collected prior to 1 January 2002; magnesium commenced >24 hours postinjury; magnesium therapy for <24 hours. Statistical analysis was conducted using Stata (V.13.1).

RESULTS

The pooled results of six studies found all-cause mortality not to be significantly different in the treatment group (RR 0.84, 95% CI 0.54 to 1.33; P=0.46) with an I² value of >70%. With regard to the secondary outcomes, no significant difference in GOS scores between treatment and control was demonstrated. GCS showed a significant improvement in the treatment group.

CONCLUSIONS

The meta-analysis found a lack of evidence for magnesium pharmacotherapy in severe TBI, although the data were noted to be conflicting and significantly heterogeneous. Further study is recommended to ascertain whether a therapeutic window exists for magnesium in severe TBI.

Time-dependent differences in cortical measures and their associations with behavioral measures following mild traumatic brain injury

There is currently a critical need to establish an improved understanding of time-dependent differences in brain structure following mild traumatic brain injury (mTBI). We compared differences in brain structure, specifically cortical thickness (CT), cortical volume (CV), and cortical surface area (CSA) in 54 individuals who sustained a recent mTBI and 33 healthy controls (HCs). Individuals with mTBI were split into three groups, depending on their time since injury. By comparing structural measures between mTBI and HC groups, differences in CT reflected cortical thickening within several areas following 0-3 (time-point, TP1) and 3-6 months (TP2) post-mTBI. Compared with the HC group, the mTBI group at TP2 showed lower CSA within several areas. Compared with the mTBI group at TP2, the mTBI group during the most chronic stage (TP3: 6-18 months post-mTBI) showed significantly higher CSA in several areas. All the above reported differences in CT and CSA were significant at a cluster-forming p < .01 (corrected for multiple comparisons). We also found that in the mTBI group at TP2, CT within two clusters (i.e., the left rostral middle frontal gyrus (L. RMFG) and the right postcentral gyrus (R. PostCG)) was negatively correlated with basic attention abilities (L. RMFG: r = -.41, p = .05 and R. PostCG: r = -.44, p = .03). Our findings suggest that alterations in CT and associated neuropsychological assessments may be more prominent during the early stages of mTBI. However, alterations in CSA may reflect compensatory structural recovery during the chronic stages of mTBI.

Quality of return to work in patients with mild traumatic brain injury: a prospective investigation of associations among post-concussion symptoms, neuropsychological functions, working status and stability

PRIMARY OBJECTIVE

Although 'return to work' (RTW) has been always emphasized for patients with mild traumatic brain injury (MTBI), methodological drawbacks weakened its representativeness. This study thus aims to evaluate the 'work quality' (WQ) which originated from 'working status' and 'working stability' simultaneously, and to further explore the associations among post-concussion symptoms (PCS), neuropsychological functions and WQ.

METHODS AND PROCEDURES

A total of 179 participants, which included 132 patients with MTBI and 47 healthy participants, were prospectively recruited. The work quality index (WQI) was developed to evaluate WQ. All patients were evaluated for their PCS, neuropsychological functions and WQ at two weeks post-injury (T1), while PCS and WQ were recorded by one month post-injury (T2).

RESULTS

More than half of the patients were not able to retain their pre-injury jobs at T1, while 26% of the patients still failed to regain previous works at T2. Interestingly, WQ was significantly associated with educational levels and physical PCS, such as headache and dizziness.

CONCLUSIONS

Simultaneously considering working status and stability to reveal the quality of RTW is merited. A higher educational level might be a protective factor for successful RTW, and ameliorating physical symptoms is also necessary to get favourable WQ by one month after MTBI.

Mild Traumatic Brain Injury Chronically Impairs Sleep- and Wake-Dependent Emotional Processing

Study Objectives

A single traumatic brain injury (TBI), even when mild (ie, concussion), can cause lasting consequences. Individuals with a history of chronic (>1-year prior) mild TBI have an increased risk of mood disturbances (eg, depression, suicide). This population also has lingering sleep alterations, including poor sleep quality and changes in sleep stage proportions. Given these sleep deficits, we aimed to test whether sleep-dependent emotional memory consolidation is reduced in this population. We utilized a mild TBI group (3.7 ± 2.9 years post injury) and an uninjured (non-TBI) population.

Methods

Participants viewed negative and neutral images both before and after a 12-hour period containing sleep ("Sleep" group) or an equivalent period of time spent awake ("Wake" group). Participants rated images for valence/arousal at both sessions, and memory recognition was tested at session two.

Results

The TBI group had less rapid eye movement (REM), longer REM latency, and more sleep complaints. Sleep-dependent memory consolidation of nonemotional images was present in all participants. However, consolidation of negative images was only present in the non-TBI group. A lack of differentiation between the TBI Sleep and Wake groups was due to poor performance in the sleep group and, unexpectedly, enhanced performance in the wake group. Additionally, although the non-TBI participants habituated to negative images over a waking period, the TBI participants did not.

Conclusions

We propose disrupted sleep- and wake-dependent emotional processing contributes to poor emotional outcomes following chronic, mild TBI. This work has broad implications, as roughly one-third of the US population will sustain a mild TBI during their lifetime.

Sleep-Wake Disturbances After Traumatic Brain Injury: Synthesis of Human and Animal Studies

Sleep-wake disturbances following traumatic brain injury (TBI) are increasingly recognized as a serious consequence following injury and as a barrier to recovery. Injury-induced sleep-wake disturbances can persist for years, often impairing quality of life. Recently, there has been a nearly exponential increase in the number of primary research articles published on the pathophysiology and mechanisms underlying sleep-wake disturbances after TBI, both in animal models and in humans, including in the pediatric population. In this review, we summarize over 200 articles on the topic, most of which were identified objectively using reproducible online search terms in PubMed. Although these studies differ in terms of methodology and detailed outcomes; overall, recent research describes a common phenotype of excessive daytime sleepiness, nighttime sleep fragmentation, insomnia, and electroencephalography spectral changes after TBI. Given the heterogeneity of the human disease phenotype, rigorous translation of animal models to the human condition is critical to our understanding of the mechanisms and of the temporal course of sleep-wake disturbances after injury. Arguably, this is most effectively accomplished when animal and human studies are performed by the same or collaborating research programs. Given the number of symptoms associated with TBI that are intimately related to, or directly stem from sleep dysfunction, sleep-wake disorders represent an important area in which mechanistic-based therapies may substantially impact recovery after TBI.

Short-term neurocognitive and symptomatic outcomes following mild traumatic brain injury: A prospective multi-centre observational cohort study

OBJECTIVE

To determine the short-term cognitive and symptomatic outcome following mild traumatic brain injury.

METHODS

Setting: Emergency Departments of two UK tertiary referral hospitals.

PARTICIPANTS

Adult patients presenting to the Emergency Departments of the Royal London Hospital and Salford Royal Hospital with suspected traumatic brain injury within 24 hours and Glasgow Coma Score > 8. A non-TBI comparison group included adult patients with no head or neck injury.

DESIGN

Prospective multi-centre cohort study.

MAIN MEASURES

The Standardized Assessment of Concussion (SAC), the Concussion Symptom Inventory (CSI) and total number of symptoms, measured at baseline and 72 hours.

RESULTS

This study enrolled 189 patients with and 51 patients without TBI. Patients with TBI had marked cognitive impairment which persisted at 72 hours (SAC score at baseline = 25 [23-27] vs 72 hours = 25 [22-27]; p = 0.1). Patients with TBI had persistent high symptom severity, although this had decreased at 72 hours (CSI score at baseline = 9 [4-22] vs 72 hours = 5 [1-19], p = 0.002). A similar pattern was observed with the total number of symptoms (baseline = 4 [2-8] vs 72 hours = 0 [0-4]; p < 0.001). Patients with TBI had worse neurocognitive function, higher overall symptom severity and higher total number of symptoms compared with patients without TBI. Patients without TBI' neurocognitive function and symptom severity remained constant, but the number of symptoms reduced between baseline and 72 hours.

CONCLUSION

There is a cognitive deficit and symptom burden in patients with mild TBI presenting to the Emergency Department which persists at 72 hours.

Factors influencing community case management and care hours for clients with traumatic brain injury living in the UK

OBJECTIVE

To investigate the relationship between deficits associated with traumatic brain injury (TBI) and case management (CM) and care/support (CS) in two UK community samples.

RESEARCH DESIGN

Prospective descriptive study.

METHOD

Case managers across the UK and from a single UK CM service contributed client profiles to two data sets (Groups 1 and 2, respectively). Data were entered on demographics, injury severity, functional skills, functional-cognition (including executive functions), behaviour and CM and CS hours. Relationships were explored between areas of disability and service provision.

RESULTS

Clients in Group 2 were more severely injured, longer post-injury and had less family support than clients in Group 1. There were few significant differences between Groups 1 and 2 on measures of Functionalskill, Functional-cognition and Behaviour disorder. Deficits in Functionalskills were associated with CS, but not CM. Deficits in measures of executive functions (impulsivity, predictability, response to direction) were related to CM, but not to CS. Insight was related to both CM and CS. Variables related to behaviour disorder were related to CM, but were less often correlated to CS.

CONCLUSIONS

The need for community support is related not only to Functionalskills (CS), but also to behaviour disorder, self-regulatory skills and impaired insight (CM).

Epidemiology of sports-related concussion in seven US high school and collegiate sports

BACKGROUND

The epidemiology of sports-related concussion is not well-described in the literature. This paper presents a descriptive epidemiology of concussion in seven high school and collegiate sports.

METHODS

We used the data from Concussion Prevention Initiative (CPI), which enrolled 8905 athletes at 210 high schools and 26 colleges in a prospective cohort study of 7 sports (football, men's and women's soccer, men's and women's lacrosse, and men's and women's ice hockey) between 1999 and 2001. Injury risks and injury rates were used to characterize the incidence of concussion, and changes in symptoms over time were described.

RESULTS

A total of 375 concussions were observed. The incidence of concussion was highest in football, followed by women's lacrosse, men's lacrosse, men's soccer, and women's soccer (only 10 ice hockey teams were included, too few to quantify incidence). The rate of incident concussion was strongly associated with history of concussion in the previous 24 months (rate ratio = 5.5; 95 %CI: 3.9, 7.8, for 2 or more concussions relative to no previous concussion). The most common symptoms at time of injury were headache (87 %), balance problems/dizziness (77 %), and feeling "in a fog" (62 %). Loss of consciousness and amnesia were present in relatively few cases (9 and 30 %). The most common mechanism of injury was collision with another player.

CONCLUSIONS

Sports-related concussions present with a diverse range of symptoms and are associated with previous concussion history.

Return to work following mild traumatic brain injury

OBJECTIVE

To examine factors relating to return to work (RTW) following mild traumatic brain injury (mTBI).

PARTICIPANTS

One hundred and nine patients (Age: M = 37.4 years, SD = 13.2; 52.3% women) who sustained an mTBI.

DESIGN

Inception cohort design with questionnaires and neuropsychological testing completed approximately 3 to 4 weeks postinjury.

SETTING

Emergency Department of Tampere University Hospital, Finland.

MAIN OUTCOME MEASURES

Self-report (postconcussion symptoms, depression, fatigue, and general health) and neurocognitive measures (attention and memory).

RESULTS

The cumulative RTW rates were as follows: 1 week = 46.8%, 2 weeks = 59.6%, 3 weeks = 67.0%, 4 weeks = 70.6%, 2 months = 91.7%, and 1 year = 97.2%. Four variables were significant predictors of the number of days to RTW: age, multiple bodily injuries, intracranial abnormality at the day of injury, and fatigue ratings (all P < .001). The largest amount of variance accounted for by these variables in the prediction of RTW was at 30 days following injury (P < .001, R = 0.504). Participants who returned to work fewer than 30 days after injury (n = 82, 75.2%) versus more than 30 days (n = 27, 24.8%) did not differ on demographic or neuropsychological variables.

CONCLUSIONS

The vast majority of this cohort returned to work within 2 months. Predictors of slower RTW included age, multiple bodily injuries, intracranial abnormality at the day of injury, and fatigue.

You Cannot Go Home: Routine Concussion Evaluation is not Enough

Traditional care of mild traumatic brain injury (MTBI) is to discharge patients from the emergency department (ED) if they have a Glasgow Coma Score (GCS) of 15 and a normal head computed tomography (CT) scan. However, this does not address short-term neurocognitive deficits. Our hypothesis is that a notable percentage of patients will need outpatient neurocognitive therapy despite a reassuring initial presentation. This is a retrospective review of patients with MTBI at an urban Level I trauma center. Inclusion criteria were a diagnosis of MTBI in patients 14 years old or older, GCS 15, negative head CT scan, a completed neurocognitive evaluation, blunt mechanism, and no confounding psychiatric comorbidities. Six thousand thirty-two patients were admitted over 18 months. Three hundred ninety-five patients met inclusion criteria. Average age was 38 years (range, 14 to 93 years), 64 per cent were male, and mean Injury Severity Score (ISS) was 8.1. Forty-one per cent were cleared for discharge without follow-up. Twenty-seven per cent required ongoing neurocognitive therapy. Three per cent were deemed unsafe for discharge home. Of the patients cleared for discharge, 88 per cent had positive/questionable loss of consciousness (LOC), whereas 81 per cent who required additional therapy had positive/questionable LOC ( P = 0.20). Age, gender, ISS, and alcohol use were compared between the groups and not found to be statistically different rendering them poor predictors for appropriate discharge from the ED. A surprisingly high percentage (27%) of patients who would have met traditional ED discharge criteria were found to have persistent deficits after neurocognitive testing and were referred for ongoing therapy. We provide evidence to suggest that we should take pause before discharging patients with MTBI without a cognitive evaluation.

Epidemiology of work-related traumatic brain injury: a systematic review

OBJECTIVE

This systematic review aimed to describe the burden and risk factors of work-related traumatic brain injury (wrTBI) and evaluate methodological quality of existing literature on wrTBI.

METHODS

A search of electronic databases (MEDLINE, EMBASE, PsycINFO, and CINAHL) was conducted to identify articles published between 1980 and 2013 using a combination of terms for work, TBI, and epidemiology, without geographical limitations.

RESULTS

Ninety-eight studies were included in this review, of which 24 specifically focused on wrTBI. In general, male workers, those in the youngest and oldest age groups, and those working in the primary (e.g., agriculture, forestry, mining) or construction industries were more likely to sustain wrTBI, with falls being the most common mechanism of injury.

CONCLUSIONS

This review identified workers at highest risk of wrTBI, with implications for prevention efforts. Future research of better methodological quality is needed to provide a more complete picture of the epidemiology of wrTBI.

Actigraphic assessment of sleep disturbances following traumatic brain injury

The current study examined the use of actigraphy in measurement of sleep following traumatic brain injury (TBI). Twenty-one patients with TBI and self-reported sleep and/or fatigue problems and 21 non-injured controls were studied over seven days using actigraphy and sleep diary reports. Although strong associations between diary and actigraphic assessment of sleep duration were observed in both participant groups, agreement between these methods appeared to weaken in patients with TBI. Associations between sleep diary and actigraphic assessments of sleep disturbance, i.e., wake after sleep onset (WASO) and sleep onset latency (SOL) were not apparent in either group, although weaker agreement between methods for WASO was again observed in patients with TBI. Actigraphy may prove useful to supplement self-report measures of sleep following TBI. More work is required to understand the accuracy of these measures in this population.

Unique contribution of fatigue to disability in community-dwelling adults with traumatic brain injury

OBJECTIVE

To examine the unique contribution of fatigue to self-reported disability in community-dwelling adults with traumatic brain injury (TBI).

DESIGN

A cross-sectional cohort design.

SETTING

Community dwellings.

PARTICIPANTS

Adults (N=50) with a history of mild to severe TBI were assessed.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

This study assessed the contribution of fatigue (Modified Fatigue Impact Scale) to disability (Mayo-Portland Adaptability Inventory), controlling for executive functions (Frontal Systems Behavior Scale), depression status (major depression in partial remission/current major depression/depressive symptoms or no history of depression), and initial injury severity (uncomplicated mild, complicated mild, moderate, or severe).

RESULTS

Fatigue was found to contribute uniquely to the variance in self-reported disability (β=.47, P<.001) after controlling for injury severity, executive functions, and depression status. The overall model was significant (F(4,45)=17.32, P<.001) and explained 61% of the variance in self-reported disability, with fatigue alone accounting for 12% of the variance in self-reported disability (F(1,45)=13.97, P<.001).

CONCLUSIONS

Fatigue contributes uniquely to disability status among community-dwelling adults with chronic TBI, independent of injury severity, executive functions, and depression. Addressing fatigue through targeted interventions may help to improve self-perceived disability in this population.

National Taiwan University Irritability Scale: Evaluating Irritability in Patients With Traumatic Brain Injury

Irritability is not uncommon after traumatic brain injury (TBI). Unfortunately, no instruments are available to directly measure this clinical feature. This study thus aimed to develop a specific scale to evaluate the irritability for patients with TBI. A total of 144 participants, which include 80 healthy participants and 64 patients suffering from TBI, were recruited. Irritability was assessed by the National Taiwan University Irritability Scale (NTUIS). Our results showed the NTUIS has good reliability. The factor analysis further revealed 2 different components: annoyance, and verbal aggression. Moreover, both self-reported and family-reported irritability postinjury were significantly higher than the irritability reported by the healthy participants. Indeed patients with TBI have significant problems with irritability after injuries, and thus a more specific assessment tool to carefully evaluate patients' irritability should be used.

The development of a measure of emotional regulation following acquired brain injury

Disturbances in emotional regulation following acquired brain injury have been found to be both prevalent and particularly disabling. Despite this, relatively little attention has been given to identifying characteristics of such deficits in a systematic way. We therefore describe the development of a new questionnaire measure of disturbances in emotional regulation that may occur following acquired brain injury. The measure demonstrates excellent psychometric properties, including high test-retest (.95) and split half (.96) reliability, high internal consistency (.96), and good concurrent validity (r = .64-.82). The questionnaire measures characteristics that are distinguishable from measures of cognitive ability and from other tests of affect. There was moderate overlap between self-report and relative versions of the questionnaire. Results suggest that the relative version has the stronger predictive value. The potential uses of the measure in relation to theory and practice are discussed.

Application of the Hill criteria to the causal association between post-traumatic headache and assault

Post-traumatic headache (PTH) is a common and disabling symptom secondary to the traumatic event. It is known that assault is associated with a wide range of physical symptoms including PTH. In this work, the general causation approach provided by the Hill criteria is described as an assessment tool for specific causation with regards to PTH and sexual assault. Time-dependent models of probability and, in-turn, relative risk are described as quantitative algorithms for addressing inductive and abductive conclusions of causation in forensic science.

Sleep disorders in patients with traumatic brain injury: a review

Traumatic brain injury (TBI) is a global problem and causes long-term disability in millions of individuals. This is a major problem for both military- and civilian-related populations. The prevalence of sleep disorders in individuals with TBI is very high, yet mostly unrecognized. Approximately 46% of all chronic TBI patients have sleep disorders, which require nocturnal polysomnography and the Multiple Sleep Latency Test for diagnosis. These disorders include sleep apnoea (23% of all TBI patients), post-traumatic hypersomnia (11%), narcolepsy (6%) and periodic limb movements (7%). Over half of all TBI patients will have insomnia complaints, most often with less severe injury and after personal assault, and half of these may be related to a circadian rhythm disorder. Hypothalamic injury with decreased levels of wake-promoting neurotransmitters such as hypocretin (orexin) and histamine may be involved in the pathophysiology of excessive sleepiness associated with TBI. These sleep disorders result in additional neurocognitive deficits and functional impairment, which might be attributed to the original brain injury itself and thus be left without specific treatment. Most standard treatment regimens of sleep disorders appear to be effective in these patients, including continuous positive airway pressure for sleep apnoea, pramipexole for periodic limb movements and cognitive behavioural therapy for insomnia. The role of wake-promoting agents and CNS stimulants for TBI-associated narcolepsy, post-traumatic hypersomnia and excessive daytime sleepiness requires further study with larger numbers of patients to determine effectiveness and benefit in this population. Future research with multiple collaborating centres should attempt to delineate the pathophysiology of TBI-associated sleep disorders, including CNS-derived hypersomnia and circadian rhythm disturbances, and determine definitive, effective treatment for associated sleep disorders.

Return to work following traumatic brain injury: Trends and challenges

PURPOSE

The aim of this paper is to present the current knowledge regarding return to work (RTW) following traumatic brain injury (TBI).

METHOD

Based on a Medline search, the authors reviewed the current TBI rehabilitation literature regarding (a) predictive factors for successful RTW, and (b) current concepts in rehabilitative strategies for successful RTW.

RESULTS

The functional consequences to the victim of traumatic brain injury (TBI) can be severe. Intensive rehabilitative efforts typically emphasize the early phase and address mainly the accompanying functional deficits in the realm of basic activities of daily living and mobility. An otherwise successful medical rehabilitation may end unsuccessfully because of the failure to return to work, with profound consequences to the individual and family, both economic and psychosocial. Even mild TBI may cause lasting problems in tasks calling for sustained attention. There appears to be a complex interaction between pre-morbid characteristics, injury factors, post injury impairments, personal and environmental factors in TBI patients, which influences RTW outcomes in ways that make prediction difficult. Injury severity and lack of self-awareness appear to be the most significant indicators of failure to RTW. Several medical, psychosocial and rehabilitative therapies are currently being implemented in rehabilitation settings which improve the chances of returning to work.

CONCLUSION

Accurate prediction of whether a particular TBI patient will successfully return to work is not feasible, with RTW rates in the 12 - 70% range. A significant proportion of TBI patients, including those who are severely injured, are able to return to productive employment if sufficient and appropriate effort is invested. A comprehensive approach - medical and psychosocial - eventually entailing adequate vocational rehabilitation with supported employment can improve outcomes.

Dizziness after traumatic brain injury: Results from an interview study

BACKGROUND

Dizziness is a commonly reported sequel to traumatic brain injury (TBI).

OBJECTIVE

To better define the nature of the symptomatology and the impact that dizziness has on the TBI survivor.

SETTING

A community brain injury rehabilitation programme and a community access programme for TBI survivors.

METHOD

Focus groups with TBI survivors and individual interviews with TBI survivors and some of their carers.

RESULTS

The data confirmed that dizziness is difficult for TBI survivors to define and describe and it consists of multiple symptoms. Dizziness also appears to be associated with significant functional difficulties. Additionally, many of the participants of this study reported falling. Carers reported a number of observable signs of dizziness and indicated that they believed they were able to tell when the person they cared for was dizzy.

CONCLUSION

The results provide information which will help in the development of more appropriate outcome measurement tools for dizziness after a TBI.

Fatigue before and after mild traumatic brain injury: Pre–post-injury comparisons in relation toApolipoproteinE

PRIMARY OBJECTIVE

To assess the incidence of fatigue for persons following a mild traumatic brain injury (MTBI) and to evaluate the relationship between fatigue and APOE genotype. As fatigue is often found to be influenced by anxiety, depression and sleep disturbance, these factors were also measured.

METHODS AND PROCEDURES

Thirty-one persons who sustained a MTBI were drawn from a population-based longitudinal study. Each person who sustained a MTBI was matched by age, gender, education and APOE genotype with two non-head injury controls. Self-reported pre- and post-injury incidence of fatigue, anxiety, depression and sleep disturbance was compared within-group and between groups.

RESULTS

For the MTBI group, incidence of fatigue was almost twice as common post- than pre-injury, whereas there was no corresponding change in a non-injured control group. Within the MTBI-group, post-injury fatigue was particularly common for carriers of the APOE epsilon4 allele.

CONCLUSIONS

Fatigue is common sequela after a MTBI and especially pronounced for carriers of the APOE epsilon4 allele.

Return to work following moderate-to-severe traumatic brain injury

PRIMARY OBJECTIVE

To investigate the role of cognitive functioning, fatigue, mood and behaviour in return to work (RTW) following moderate-to-severe traumatic brain injury.

DESIGN AND METHODS

Between-groups comparisons were conducted with 20 participants who had RTW and 13 who had not. Participants were well matched for age, pre-morbid intellectual functioning, years of education, injury severity and time since injury.

OUTCOMES AND RESULTS

The unemployed group reported significantly higher levels of fatigue and depression and significantly more problems on self-report questionnaires. A significantly higher proportion of this group was seeking compensation. No significant differences were obtained on neuropsychological measures of cognitive functioning.

CONCLUSIONS

Mood, fatigue and behavioural problems may impede a person's ability to RTW. Subjective measures may be more superior to objective measures in predicting RTW. The litigation process may affect people's motivation to RTW.

Dizziness after traumatic brain injury: Overview and measurement in the clinical setting

Traumatic brain injury (TBI) may result in a variety of cognitive, behavioural and physical impairments. Dizziness has been reported in up to 80% of cases within the first few days after injury. The literature was reviewed to attempt to delineate prevalence of dizziness as a symptom, impairments causing dizziness, the functional limitations it causes and its measurement. The literature provides widely differing estimates of prevalence and vestibular system dysfunction appears to be the best reported of impairments contributing to this symptom. The variety of results is discussed and other possible causes for dizziness were reviewed. Functional difficulties caused by dizziness were not reported for this population in the literature and review of cognitive impairments suggests that existing measurement tools for dizziness may be problematic in this population. Research on the functional impact of dizziness in the TBI population and measurement of these symptoms appears to be warranted.

Baseline predictors of fatigue 1 year after mild head injury

OBJECTIVE

To compare reports of fatigue 12 months after minor trauma by participants with mild head injury (MHI) with those with other injury, and identify injury and baseline predictors of fatigue.

DESIGN

An inception cohort study of participants with MHI and other nonhead injuries recruited from and interviewed at the emergency department (ED), with a follow-up telephone interview at 12 months.

SETTING

Level II community hospital ED.

PARTICIPANTS

Participants (n=58) with MHI and loss of consciousness (LOC) of 30 minutes or less and/or posttraumatic amnesia (PTA) less than 24 hours, 173 with MHI but no PTA/LOC, and 128 with other mild nonhead injuries.

INCLUSION CRITERIA

age 18 years or older, within 24 hours of injury, Glasgow Coma Scale score of 13 or higher, and discharge from the ED.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Medical Outcomes Study 36-Item Short-Form Health Survey Vitality subscale.

RESULTS

Significant predictors of fatigue severity at 12 months were baseline fatigue, having seen a counselor for a mental health issue, medical disability, marital status, and in some stage of litigation. Injury type was not a significant predictor.

CONCLUSIONS

Fatigue severity 12 months after injury is associated with baseline characteristics and not MHI. Clinicians should be cautious about attributing persisting fatigue to MHI without comprehensive consideration of other possible etiologic factors.

The association between the postconcussion symptoms and clinical outcomes for patients with mild traumatic brain injury

BACKGROUND

Postconcussion symptoms (PCS) (such as dizziness, headache, irritability, fatigue, and impaired memory) are common in patients who sustain a mild traumatic brain injury (mTBI). However, few studies have systematically investigated the association between PCS and clinical outcomes in mTBI patients. Therefore, the present study attempted to examine PCS during the disease course and to determine whether PCS adversely affect outcome.

METHODS

This was a prospective, cohort and controlled study of 115 mTBI patients. The PCS checklist was used to identify PCS and the Glasgow Outcome Scale and the Glasgow Outcome Scale-Extended were used to investigate clinical outcomes. All patients were evaluated four times: at 1 week, 2 weeks, 4 weeks, and 8 weeks after the injury.

RESULTS

Physical symptoms such as dizziness and headache were prominent in the early after injury stage (1 and 2 weeks). On the other hand, the psychosocial symptoms, such as depression and irritability, were significant at the late after injury stage (4 and 8 weeks). Dizziness adversely affected clinical outcome at both the early and late stages of the disease, whereas the impact of intracranial lesions and depression on outcome was greatest early and late, respectively.

CONCLUSIONS

The results show that PCS during the disease course and the relationship between PCS and clinical outcome can be systematically evaluated. In fact, different postconcussion symptom domains should be monitored while the disease is progressing.