Patients “At Risk” of Suffering from Persistent Complaints after Mild Traumatic Brain Injury: The Role of Coping, Mood Disorders, and Post-Traumatic Stress

Medical Care Among Individuals with a Concussion in Ontario: A Population-based Study

BACKGROUND

Concussion affects 1.2% of the population annually; rural regions and children have higher rates of concussion.

METHODS

Using administrative health care linked databases, all residents of Ontario with a physician diagnosed concussion were identified using ICD-9 code 850 or ICD-10 code S06. Cases were tracked for 2 years for concussion-related health care utilization with relevant specialist physicians (i.e., neurology, otolaryngology, physiatry, psychiatry, ophthalmology). Billing codes, specialist codes, and time from index to visit were analyzed. Factors associated with increased specialist visits were also examined.

RESULTS

In total, 1,022,588 cases were identified between 2008 and 2014 with 2 years of post-concussion health care utilization available. Follow-up by physician within 3 days of injury occurred in only 14% of cases. Mean time between ED diagnosis and follow-up by a physician was 83.9 days, whereas for rural regions it was >100 days. About half of adults (51.9%) and children (50.3%) had at least 1 specialist visit following concussion. Mean time between injury and first specialist visit was 203.8 (SD 192.9) days for adults, 213.5 (SD 201.0) days for rural adults, and 276.0 (SD 202.6) days for children. There were 67,420 neurology visits, 70,404 psychiatry visits, 13,571 neurosurgery visits, 19,780 physiatry visits, 101,788 ENT visits, and 103,417 ophthalmology visits in the 2 years tracking period. Factors associated with more specialist use included age > 18 years, urban residence, and pre-injury psychiatric history.

CONCLUSIONS

There are discrepancies in post-concussion health care utilization based on age group and rural/urban residence. Addressing these risk factors could improve concussion care access.

From acute stress to persistent post-concussion symptoms: The role of parental accommodation and child's coping strategies

Background: Acute stress following mild Traumatic Brain Injury (mTBI) is highly prevalent and associated with Persistent Post-Concussion symptoms (PPCS). However, the mechanism mediating this relationship is understudied. Objective: To examine whether parental accommodation (i.e. parents' attempts to adjust the environment to the child's difficulties) and child's coping strategies mediate the association between acute stress and PPCS in children following mTBI. Method: Participants were 58 children aged 8-16 who sustained a mTBI and their parents. Children's acute stress (one-week post-injury) and coping strategies (three weeks post-injury), and parental accommodation (three weeks and four months post-injury) were assessed. Outcome measures included PPCS (four months post-injury) and neuropsychological tests of cognitive functioning (attention and memory). A baseline for PPCS was obtained by a retrospective report of pre-injury symptoms immediately after the injury. Results: Children's acute stress and negative coping strategies (escape-oriented coping strategies) and four-months parental accommodation were significantly related to PPCS. Acute stress predicted PPCS and attention and memory performance. Parental accommodation significantly mediated the association between acute stress and PPCS. Conclusions: Stress plays an important role in children's recovery from mTBI and PPCS. Parental accommodation mediates this relationship, and thus, clinical attention to parental reactions during recovery is needed.

Atypical symptom reporting after mild traumatic brain injury

OBJECTIVE

Early reporting of atypical symptoms following a mild traumatic brain injury (mTBI) may be an early indicator of poor prognosis. This study aimed to determine the percentage of people reporting atypical symptoms 1-month post-mTBI and explore links to recovery 12 months later in a community-dwelling mTBI sample.

METHODS

Adult participants (>16 years) who had experienced a mTBI were identified from a longitudinal incidence study (BIONIC). At 1-month post-injury, 260 participants completed the Rivermead Post-Concussion Symptoms Questionnaire (typical symptoms) plus four atypical symptom items (hemiplegia, difficulty swallowing, digestion problems and difficulties with fine motor tasks). At 12 months post-injury, 73.9% (n = 193) rated their overall recovery on a 100-point scale. An ordinal regression explored the association between atypical symptoms at 1 month and recovery at 12 months post-injury (low = 0-80, moderate = 81-99 and complete recovery = 100), whilst controlling for age, sex, rehabilitation received, ethnicity, mental and physical comorbidities and additional injuries sustained at the time of injury.

RESULTS

At 1-month post-injury <1% of participants reported hemiplegia, 5.4% difficulty swallowing, 10% digestion problems and 15.4% difficulties with fine motor tasks. The ordinal regression model revealed atypical symptoms were not significant predictors of self-rated recovery at 12 months. Older age at injury and higher typical symptoms at 1 month were independently associated with poorer recovery at 12 months, p < 0.01.

CONCLUSION

Atypical symptoms on initial presentation were not linked to global self-reported recovery at 12 months. Age at injury and typical symptoms are stronger early indicators of longer-term prognosis. Further research is needed to determine if atypical symptoms predict other outcomes following mTBI.

[Formula: see text]Persistent post-concussion symptoms in children: pre-injury social difficulties and acute stress reaction as risk factors

Following mild traumatic brain injury (mTBI) children usually experience one or more somatic, cognitive, and/or emotional-behavioral post-concussion symptoms (PCS). PCS may be transient, however for some children, persistent post-concussion symptoms (PPCS) might linger for months or years. Identifying risk factors for PPCS may allow earlier interventions for patients at greater risk. We examined pre-injury social difficulties and acute stress reaction as risk factors to PPCS in children. Participants were 83 children (aged 8-16) with mTBI. In a prospective follow-up, pre-injury social difficulties, 24-hours post-concussion symptoms, and acute stress reactions were tested as predictors of one-week and four-months PCS reports. Parents' reports, self-reports, and neurocognitive tests were employed. One-week PCS level was associated with acute stress, and not with 24-hours post-concussion symptoms or pre-injury social difficulties. Four-months PCS level was predicted by pre-injury social difficulties and 24-hours post-concussion symptoms, with no contribution of acute stress. Interestingly, less symptoms at 24-hour from injury were associated with a higher level of PCS at four months. Cognitive functioning at four months was predicted by acute stress, with no contribution of 24-hours post-concussion symptoms or pre-injury social difficulties. Cognitive functioning did not differ between children with and without PPCS. In conclusion, non-injury, socio-emotional factors (pre-injury social difficulties, acute stress) should be considered, alongside injury-related factors, in predicting recovery from mTBI. Pre-injury social difficulties and stress reaction to the traumatic event might pose an emotional burden and limit one's social support during recovery, thus require clinical attention in children following mTBI.

Post-concussion symptoms 1-year after traumatic brain injury: using the Rivermead Post-concussion Questionnaire to identify predictors of severity

BACKGROUND

Patients who suffer traumatic brain injury (TBI) often experience a constellation of physical, cognitive, and emotional/behavioral symptoms called "post-concussion symptoms" and subsequent long-term disability. This study aimed to investigate the incidence of persistent post-concussion symptoms and possible predictors of long-term disability focusing on demographic, injury, and psychological factors. It was hoped to identify groups at high risk.

METHODS

A prospective cohort of 1322 individuals admitted with TBI were assessed in a specialist neurorehabilitation clinic at 10 weeks and 1-year post injury between August 2011 and July 2015. The outcome (post-concussion symptoms) was measured using the Rivermead Post-concussion Questionnaire (RPQ) at 1-year post injury.

RESULTS

At 1 yr, 1131 individuals were identified (>90% follow-up). Over 20% exhibited moderate or severe symptom levels on RPQ. A linear regression model showed that previous psychiatric history, lower Glasgow Coma Scale (GCS), severe CT abnormalities, injury caused by assault, pre-injury unemployment, and inability to return to work at 6 weeks post-injury were associated with worse symptoms at 1 yr. The adjusted R² of the model was 25.1%.

CONCLUSION

These findings confirm the high incidence of post-concussion symptoms at 1 yr and identify certain associated features that increase risk. This may allow targeting of certain groups, e.g., return to work or victims of assault.

Perceptions of Concussion and Associated Anxiety in Irish Collegiate Athletes

BACKGROUND

Concussion nondisclosure and poor management after a concussion are a concern in Irish collegiate sports. How athletes perceive concussions and appraise their own concussion may affect their decisions and behaviors after a suspected concussion. However, this has yet to be examined in an Irish context. This study aimed to (1) establish concussion perceptions and associated anxiety in Irish collegiate athletes; (2) examine how sex, concussion, and mood disorder history influenced their perceptions; and (3) investigate factors associated with higher anxiety perceptions.

HYPOTHESIS

Irish collegiate athletes will display negative concussion perceptions and anxiety related to concussion, especially in female athletes and those without a concussion history.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 3.

METHODS

Irish collegiate athletes [n = 268 (141 women,127 men), mean age = 21.5 ± 2.2 years] from high-risk sports completed a survey including the Perceptions of Concussion Inventory for Athletes (PCI-A), demographics, diagnosed concussion history, self-reported mood disorder history, and a concussion knowledge assessment. Differences in concussion perceptions by sex, concussion history, mood disorder history were examined using Mann-Whitney U tests, and factors associated with anxiety-related concussion perceptions were identified using multivariate logistic regression.

RESULTS

Over half (53.0%, n = 142) of participants reported concerns regarding concussion. The thoughts of sustaining a concussion made participants feel upset (63.4%, n = 170), fearful (47.7%, n = 128), and anxious (35.1%, n = 94). Women reported significantly higher anxiety (P < 0.01, r = 0.23), effects (P = 0.04, r = 0.12), and clarity (P = 0.01, r = 0.16) perception scores. Participants with a diagnosed concussion history displayed greater symptom variability perception scores (P = 0.04, r = 0.12), but lower anxiety (P = 0.03, r = 0.13) and treatment (P < 0.01, r = 0.19) beliefs on the PCI-A. No differences were observed for those with a history of a mood disorder (P > 0.05). A significant multivariate model was established (χ² = 55.44, P < 0.01), with female sex [odds ratio (OR) = 1.53], concussion history (OR = 0.63), effects (OR = 1.31), and treatment (OR = 1.15) subscales associated with greater anxiety.

CONCLUSION

Concerns about sustaining a concussion are prevalent in Irish collegiate athletes. Women displayed more negative perceptions and those with a concussion history displayed fewer perceived benefits of treatment.

CLINICAL RELEVANCE

The findings support the need for concussion awareness campaigns to provide accurate concussion information to mitigate anxiety-related concussion perceptions and injury belief misconceptions.

Depression and Anxiety in Patients With a History of Traumatic Brain Injury: A Case-Control Study

Background

The burden of psychiatric illness following a head injury may have implications on the disease prognosis. The present study evaluated the association of depression and anxiety with traumatic brain injury (TBI).

Methods

A case-control study was conducted in Karachi, Pakistan, from 2nd July 2021 and 30th January 2022, including individuals of age 18 and above of both genders, with or without a mild head trauma history, forming the case and control groups, respectively. Individuals with previous head trauma/congenital neurological dysfunction were excluded. A mental health assessment of the participants was carried out with two scales, the Generalized Anxiety Disorder-7 (GAD-7) scale and the Public Health Questionnaire-9 (PHQ-9) scale. Other parameters like age, gender, socioeconomic status, education status, and comorbidities were also documented.

Results

A total of 62 participants were enrolled with 31 cases and 31 controls. The majority were males aged between 18 and 39 years. About 29% of the patients with a history of mild TBI had moderate to severe depression while only 22.6% of them did not have depression or had minimal depression. We found that about 29.3% of patients with TBI had severe anxiety as compared to the only two healthy controls. The majority of the control group participants did not have anxiety.

Conclusion

Traumatic head injuries and their long-term side effects can predispose patients to a myriad of psychiatric comorbidities. In this study, we found definitive evidence that both anxiety and depression had a significantly higher incidence in cohorts that suffered from mild TBI. However, we recommend large-scale and multicenter studies in the future to explore these relationships more thoroughly and comprehensively.

Systematic Review and Meta-analysis of Outcome after Mild Traumatic Brain Injury in Older People

OBJECTIVE

Older age is often identified as a risk factor for poor outcome from traumatic brain injury (TBI). However, this relates predominantly to mortality following moderate-severe TBI. It remains unclear whether increasing age exerts risk on the expected recovery from mild TBI (mTBI). In this systematic review of mTBI in older age (60+ years), a focus was to identify outcome through several domains - cognition, psychological health, and life participation.

METHODS

Fourteen studies were identified for review, using PRISMA guidelines. Narrative synthesis is provided for all outcomes, from acute to long-term time points, and a meta-analysis was conducted for data investigating life participation.

RESULTS

By 3-month follow-up, preliminary findings indicate that older adults continue to experience selective cognitive difficulties, but given the data it is possible these difficulties are due to generalised trauma or preexisting cognitive impairment. In contrast, there is stronger evidence across time points that older adults do not experience elevated levels of psychological distress following injury and endorse fewer psychological symptoms than younger adults. Meta-analysis, based on the Glasgow Outcome Scale at 6 months+ post-injury, indicates that a large proportion (67%; 95% CI 0.569, 0.761) of older adults can achieve good functional recovery, similar to younger adults. Nevertheless, individual studies using alternative life participation measures suggest more mixed rates of recovery.

CONCLUSIONS

Although our initial review suggests some optimism in recovery from mTBI in older age, there is an urgent need for more investigations in this under-researched but growing demographic. This is critical for ensuring adequate health service provision, if needed.

The Association Between Perceived Risk of COVID-19, Psychological Distress, and Internet Addiction in College Students: An Application of Stress Process Model

The closed-off management of the university during coronavirus disease 2019 (COVID-19) may be associated with an elevated odds of psychological and behavioral issues among college students. We aimed to use the stress-process model to explore the potential mechanisms for this phenomenon. A total of 924 college students were recruited via posters, peer referrals, and class attendance. Among them, 82 (9%) were probable depression, 190 (20.8%) were probable anxiety, and 69 (7.5%) were internet addiction. Parallel mediation was used to test this theoretical model. For personal resources, the perceived risk of COVID-19 was positively associated with psychological distress via negative coping style (β = 0.051) and internet addiction via negative coping style or self-esteem (β = 0.023 for negative coping style, β = 0.015 for self-esteem). For social resources, the perceived risk of COVID-19 was positively associated with psychological distress and internet addiction via roommate relationships (β = 0.19 for psychological distress, β = 0.046 for internet addiction). Negative coping styles and roommate relationships are possible psychological mechanisms linking the perceived risk of COVID-19, psychological distress, and internet addiction.

Decreased Interhemispheric Functional Connectivity and Its Associations with Clinical Correlates following Traumatic Brain Injury

Objective

To explore the interhemispheric functional coordination following traumatic brain injury (TBI) and its association with posttraumatic anxiety and depressive symptoms.

Methods

This was a combination of a retrospective cohort study and a cross-sectional observational study. We investigated the functional coordination between hemispheres by voxel-mirrored homotopic connectivity (VMHC). Grey matter volumes were examined by voxel-based morphometry (VBM), and microstructural integrity of the corpus callosum (CC) was assessed by diffusion tension imaging (DTI). The anxiety and depressive symptoms were evaluated with the Hospital Anxiety and Depression Scale.

Results

The VMHC values of the bilateral middle temporal gyrus (MTG) and orbital middle frontal gyrus (MFG) were significantly decreased in TBI patients versus the healthy controls. Weakened homotopic functional connectivity (FC) in the bilateral orbital MFG is moderate positively correlated with anxiety and depressive symptoms. The white matter integrity in the CC was extensively reduced in TBI patients. In the receiver operating characteristic analysis, the VMHC value of the orbital MFG could distinguish TBI from HC with an area under the curve of 0.939 (sensitivity of 1 and specificity of 0.867).

Conclusion

TBI disrupts the interhemispheric functional and structural connection, which is correlated with posttraumatic mood disorders. These findings may serve as a clinical indicator for diagnosis.

Neuropsychiatric Treatment for Mild Traumatic Brain Injury: Nonpharmacological Approaches

Postconcussive symptoms following mild traumatic brain injury (mTBI)/concussion are common, disabling, and challenging to manage. Patients can experience a range of symptoms (e.g., mood disturbance, headaches, insomnia, vestibular symptoms, and cognitive dysfunction), and neuropsychiatric management relies heavily on nonpharmacological and multidisciplinary approaches. This article presents an overview of current nonpharmacological strategies for postconcussive symptoms including psychoeducation; psychotherapy; vestibular, visual, and physical therapies; cognitive rehabilitation; as well as more novel approaches, such as neuromodulation. Ultimately, treatment and management of mTBI should begin early with appropriate psychoeducation/counseling, and be tailored based on core symptoms and individual goals.

Examining the association between psychosocial functioning and concussion symptom severity in youth

OBJECTIVE

Guidelines recommend examining psychosocial variables as contributors to postconcussive symptoms. However, few studies examined this relation in a clinic-referred sample and fewer accounted for parent perspective, limiting practitioners implementation of this guidance. Therefore, this longitudinal study examined youth and parent-reported psychosocial variables and their association with concussion symptom severity in a clinic-referred sample of youth receiving treatment for concussion.

METHODS

Youth (n = 121; mean age = 15.3 years) with a recent concussion and their parents completed measures assessing youth depression, anxiety, academic stress, quality of life and concussion symptom severity at the initial treatment appointment and again approximately three-months later or at discharge, whichever came first.

RESULTS

Differences were observed in psychosocial functioning across parent and youth report. Youth-reported depression was strongly associated with concussion symptom severity whereas parent-reported depression, academic stress, and quality of life were significantly related to concussion symptom severity. Exploratory findings of the relation between psychosocial variables at initial evaluation and concussion symptom severity at follow-up are offered.

CONCLUSION

Results offer guidance on the underlying psychosocial variables that may be useful to consider when developing interventions for youth recovering from concussion, especially those with a prolonged recovery.

Long-term increase in sensitivity to ketamine's behavioral effects in mice exposed to mild blast induced traumatic brain injury

Neurobehavioral deficits emerge in nearly 50% of patients following a mild traumatic brain injury (TBI) and may persist for months. Ketamine is used frequently as an anesthetic, analgesic and for management of persistent psychiatric complications. Although ketamine may produce beneficial effects in patients with a history of TBI, differential sensitivity to its impairing effects could make the therapeutic use of ketamine in TBI patients unsafe. This series of studies examined male C57BL/6 J mice exposed to a mild single blast overpressure (mbTBI) for indications of altered sensitivity to ketamine at varying times after injury. Dystaxia (altered gait), diminished sensorimotor gating (reduced prepulse inhibition) impaired working memory (step-down inhibitory avoidance) were examined in mbTBI and sham animals 15 min following intraperitoneal injections of saline or R,S-ketamine hydrochloride, from day 7-16 post injury and again from day 35-43 post injury. Behavioral performance in the forced swim test and sucrose preference test were evaluated on day 28 and day 74 post injury respectively, 24 h following drug administration. Dynamic gait stability was compromised in mbTBI mice on day 7 and 35 post injury and further exacerbated following ketamine administration. On day 14 and 42 post injury, prepulse inhibition was robustly decreased by mbTBI, which ketamine further reduced. Ketamine-associated memory impairment was apparent selectively in mbTBI animals 1 h, 24 h and day 28 post shock (tested on day 15/16/43 post injury). Ketamine selectively reduced immobility scores in the FST in mbTBI animals (day 28) and reversed mbTBI induced decreases in sucrose consumption (Day 74). These results demonstrate increased sensitivity to ketamine in mice when tested for extended periods after TBI. The results suggest that ketamine may be effective for treating neuropsychiatric complications that emerge after TBI but urge caution when used in clinical practice for enhanced sensitivity to its side effects in this patient population.

"I Couldn't Be Better": Assessing Self-Awareness With the Mayo-Portland Adaptability Inventory-4 Following TBI

INTRODUCTION/OBJECTIVE

To describe level of awareness, as assessed by the Mayo-Portland Adaptability Inventory-4 (MPAI-4), across physical, cognitive, functional, and emotional domains in individuals with mild, moderate, and severe traumatic brain injury (TBI) participating in a residential rehabilitation program. In addition, this study aimed to examine the relationship between time since injury and awareness. A novel way the MPAI-4 can be used to measure self-awareness is also presented.

METHOD

Retrospective analysis of existing data. The MPAI-4 was completed by the patient on admission, as well as by provider consensus within 2 weeks of admission. Level of awareness was determined by discrepancy scores, computed as MPAI-4 provider consensus score minus self-report MPAI-4 score, for the total score and for each index score: Ability, Adjustment, and Participation.

PARTICIPANTS

A total of 101 military veterans and active duty service members admitted to a Veterans Affairs community reintegration rehabilitation program.

RESULTS

Discrepancies between patient and provider reports of functioning were found among all severities of TBI across the MPAI-4 total score and index domains measuring Ability, Adjustment, and Participation. Interestingly, those with mild TBI endorsed greater impairments than their providers, while those with moderate and severe TBI reported less impairment on the MPAI-4 than providers. The effect of time varied across domains, and those who were more than 1 year postinjury displayed greater self-awareness.

CONCLUSION

This study highlights the importance of measuring awareness of functional ability over time and across TBI severity and introduces a novel method for doing so, using the MPAI-4 for comparison between staff and patient reports.

Barriers and facilitators to the management of mental health complications after mild traumatic brain injury

Background:

Clinical practice guidelines for mild traumatic brain injury (mTBI) management call on family physicians to proactively screen and initiate treatment for mental health complications, but evidence suggests that this does not happen consistently. The authors aimed to identify physician-perceived barriers and facilitators to early management of mental health complications following mTBI.

Methods & results:

Semi-structured interviews based on the Theoretical Domains Framework (TDF) were conducted with 11 family physicians. Interview transcripts were analyzed using directed content analysis. Factors influencing management of mental health post-mTBI were identified along five TDF domains.

Conclusion:

Family physicians could benefit from accessible and easily implemented resources to manage post-mTBI mental health conditions, having a better defined role in this process, and formalization of referrals to mental health specialists.

Best practice recommendations call for family doctors to proactively screen for and treat mental health problems that might arise after a mild traumatic brain injury (mTBI) (also known as a concussion). However, previous studies show that these recommendations are not followed consistently. The authors aimed to find reasons why this is not happening by interviewing 11 family doctors. The authors found that family doctors are mostly unaware of resources to guide their practice, are unsure about their role in mental health management, and experience difficulties in referring their patients to specialists for mental health care. Actively providing family doctors with knowledge and tools that help them initiate mental health care, as well as a structure for mental health referrals after mild traumatic brain injury, would help doctors apply best practice recommendations.

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

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

Prediction of risk of prolonged post-concussion symptoms: Derivation and validation of the TRICORDRR (Toronto Rehabilitation Institute Concussion Outcome Determination and Rehab Recommendations) score

BACKGROUND

Approximately 10% to 20% of people with concussion experience prolonged post-concussion symptoms (PPCS). There is limited information identifying risk factors for PPCS in adult populations. This study aimed to derive a risk score for PPCS by determining which demographic factors, premorbid health conditions, and healthcare utilization patterns are associated with need for prolonged concussion care among a large cohort of adults with concussion.

METHODS AND FINDINGS

Data from a cohort study (Ontario Concussion Cohort study, 2008 to 2016; n = 1,330,336) including all adults with a concussion diagnosis by either primary care physician (ICD-9 code 850) or in emergency department (ICD-10 code S06) and 2 years of healthcare tracking postinjury (2008 to 2014, n = 587,057) were used in a retrospective analysis. Approximately 42.4% of the cohort was female, and adults between 18 and 30 years was the largest age group (31.0%). PPCS was defined as 2 or more specialist visits for concussion-related symptoms more than 6 months after injury index date. Approximately 13% (73,122) of the cohort had PPCS. Total cohort was divided into Derivation (2009 to 2013, n = 417,335) and Validation cohorts (2009 and 2014, n = 169,722) based upon injury index year. Variables selected a priori such as psychiatric disorders, migraines, sleep disorders, demographic factors, and pre-injury healthcare patterns were entered into multivariable logistic regression and CART modeling in the Derivation Cohort to calculate PPCS estimates and forward selection logistic regression model in the Validation Cohort. Variables with the highest probability of PPCS derived in the Derivation Cohort were: Age >61 years ([Formula: see text] = 0.54), bipolar disorder ([Formula: see text] = 0.52), high pre-injury primary care visits per year ([Formula: see text] = 0.46), personality disorders ([Formula: see text] = 0.45), and anxiety and depression ([Formula: see text] = 0.33). The area under the curve (AUC) was 0.79 for the derivation model, 0.79 for bootstrap internal validation of the Derivation Cohort, and 0.64 for the Validation model. A limitation of this study was ability to track healthcare usage only to healthcare providers that submit to Ontario Health Insurance Plan (OHIP); thus, some patients seeking treatment for prolonged symptoms may not be captured in this analysis.

CONCLUSIONS

In this study, we observed that premorbid psychiatric conditions, pre-injury health system usage, and older age were associated with increased risk of a prolonged recovery from concussion. This risk score allows clinicians to calculate an individual's risk of requiring treatment more than 6 months post-concussion.

Self-efficacy and coping style in Iraq and Afghanistan-era veterans with and without mild traumatic brain injury and posttraumatic stress disorder

OBJECTIVE

To examine self-efficacy and coping style in combat-exposed Veterans with and without mild traumatic brain injury (mTBI) history and posttraumatic stress disorder (PTSD).

METHODS

Veterans (N = 81) were categorized into four groups: comorbid mTBI and PTSD (n = 23), PTSD-only (n = 16), mTBI-only (n = 25), and combat-exposed controls (n = 17). Outcomes included the Self-Efficacy for Symptom Management Scale and the Brief Coping Orientation to Problems Experienced.

RESULTS

Significant group effects were found on self-efficacy and coping style, even when adjusting for total mTBIs and psychiatric comorbidities. Post-hoc analyses revealed that the comorbid and PTSD-only groups generally had lower self-efficacy than the mTBI-only and control groups and that the PTSD-only group used less action-focused coping than the mTBI-only and control groups.

CONCLUSION

Our results suggest that self-efficacy and coping style vary as a function of mTBI history and PTSD status and that it may be important to integrate these malleable factors into interventions for this population.

Fear avoidance behavior in youth with poor recovery from concussion: measurement properties and correlates of a new scale

The objective of the current study was to develop a measure of fear avoidance behavior after concussion for youth and parent respondents and examine its basic psychometric properties and correlates. Children (N = 51) who were seen in a hospital concussion clinic after sustaining a concussion (M = 7.6 months, SD = 7.01) and their primary caregiver (N = 51)completed self- and informant-report measures of fear avoidance (Pediatric Fear Avoidance Behavior after Traumatic Brain Injury Questionnaire; PFAB-TBI), post-concussion symptoms (Health Behavior Inventory), emotional distress (Strengths and Difficulties Questionnaire), and quality of life (Pediatric Quality of Life Inventory Version 4.0). The self- and informant-report PFAB-TBI scores were moderately correlated (r = 0.51, p < 0.001). Neither measure demonstrated floor or ceiling effects. Both had strong internal consistency (Cronbach's α = 0.87 and 0.89, respectively). The PFAB-TBI self-report was positively correlated with somatic symptoms (r = 0.37), emotional distress (r = 0.39), and negatively associated with quality of life (r = -0.57). The PFAB-TBI informant-report was positively associated with informant reported somatic symptoms (r = 0.52) and emotional distress (r = .50) Overall, the PFAB-TBI has desirable basic measurement properties and expected correlations with clinical outcomes. This measure can potentially help clinicians and researchers better understand the impacts of fear avoidance behavior after pediatric concussion.

Traumatic brain injury and forensic evaluations: Three case studies of U.S. asylum-seekers

Traumatic brain injuries are common among refugees and asylum-seekers and can result from a range of etiologies, including intimate partner violence, gang violence, war-related trauma, and torture. Regardless of the cause, these injuries often result in a host of neuropsychiatric and other symptoms that may complicate individuals' subsequent health outcomes. For asylum-seekers, documenting prior head trauma is essential to the legal process, since traumatic brain injuries and their subsequent effects on memory and cognition may affect the ability to provide thorough testimony. Using three case vignettes, we explore how to approach the forensic evaluation of asylum-seekers with a history of traumatic brain injury, illustrating the range of etiologies and sequelae of traumatic brain injury in this complex population.

Cognitive complaint and objective cognition during the post-acute period after mild traumatic brain injury in pre-morbidly healthy adults

Primary Objective:The most widely used proxies of cognitive complaint after mTBI are post-concussion syndrome (PCS) symptom checklists, which do not have a clear relationship with cognition. This study investigated whether an mTBI-specific cognitive complaint measure would have clearer associations with objective cognition than a widely used PCS symptom checklist.Research Design:An observational design was used. A sample of 109 participants (52 mTBI and 57 healthy controls) completed a PCS symptom checklist, a cognitive complaint measure, and measures of information processing speed, attention, memory, executive function, depression and anxiety.Main Outcomes and Results:In the healthy control group, cognitive complaint was significantly associated with objective cognitive performance and was not associated with psychological status. In contrast, PCS endorsement was unrelated to objective cognition but was associated with psychological status. For the mTBI group, neither PCS endorsement nor cognitive complaint was associated with cognitive performance, but both measures were associated with psychological status.Conclusions:This study indicates that neither cognitive nor PCS symptom measures are reliable indicators of underlying cognitive function in the post-acute period after mTBI. Further, suffering an mTBI may affect the linear relationship that exists between cognitive symptom endorsement and cognitive function in healthy adults.

A survey of psychological distress among Bangladeshi people during the COVID-19 pandemic

Introduction

Previous studies conducted on the psychological impact of infectious outbreaks have found heavy psychological burdens among general population with more severe affect in the current pandemic. The main aim of this study is to examine the level of psychological distress during COVID-19 in Bangladesh and explore factors associated with higher psychological distress.

Methods

An internet-based, cross-sectional survey was conducted from March to April 2020 in Bangladesh among adults 18 years old and above using structured online questionnaires distributed through emails and other social media throughout Bangladesh with an overall response rate of 34%. Modified version of the Covid19 peritraumatic distress index (CPDI) was used to measure distress. Univariate and Bivariate analysis was used to estimate prevalence of CPDI symptoms and test for the associations between CPDI and the exposure variables. Logistic regression analyses were used to estimate the odds ratios of our outcome variable by exposure variables.

Results

Overall, 44.3% of respondents were suffering from mild to moderate distress and 9.5% were suffering from severe distress. Female respondents were 2.435 times more likely to suffer from CPDI mild to severe distress than males. As compared to Dhaka and Mymensing region of Bangladesh, odds of distress was 1.945 times more in Chittagong/Sylhet region (p-value = 0.035).

Conclusion

Large proportion of adult population in Bangladesh are experiencing psychological distress, with level of distress varies by different symptoms and predictors. This study suggest the need to develop comprehensive crisis prevention system including epidemiological monitoring, screening, and referral with targeted intervention to reduce psychological distress.

Perceived psychological stress and associated factors in the early stages of the coronavirus disease 2019 (COVID-19) epidemic: Evidence from the general Chinese population

INTRODUCTION

Coronavirus disease 2019 (COVID-19) is an acute respiratory infection caused by novel coronavirus 2019. Many individuals suffered psychological symptoms in the early stage when the epidemic was uncertain. We explored the perceived psychological stress and associated factors in the early stage of COVID-19 epidemic.

METHOD

The Perceived Stress Scale, Simplified Coping Style Questionnaire, Social Support Rating Scale and a general information questionnaire were integrated in an on-line survey conducted from February 1, 2020 until February 4, 2020. Multiple linear regression analysis was performed to explore whether coping style, social support or other factors contributed to psychological stress.

RESULTS

A total of 1638 participants were included, of whom 44.3% showed moderate psychological stress. Individuals who were younger, female, unmarried, spent more time on the disease, felt more concern about it, reported lower social support (Subjective Social support; Objective social support; Utilization social support), or showed a negative coping style were more likely to suffer higher psychological stress in the early stages of the COVID-19 epidemic.

CONCLUSION

Psychological interventions may be targeted to individuals with the risk characteristics identified in this study. It may be helpful to promote social support and positive coping style in the early stage of infectious disease epidemics. This initial evidence from the general Chinese population may be relevant to interventions in other countries for dealing with the COVID-19 and other epidemics.

User experience (re)design and evaluation of a self-guided, mobile health app for adolescents with mild Traumatic Brain Injury

Mild Traumatic Brain Injury (mTBI) is a significant cause of morbidity for adolescents. Currently, there is a lack of evidence-based interventions to address common sequelae of mTBI. To address this gap, we designed a program to promote recovery for adolescents following mTBI. Preliminary testing of the Self-Monitoring Activity Regulation and Relaxation Treatment (SMART) program demonstrated good usability but indicated a need for modifications to the program. The SMART application was redesigned with the addition of more interactive and gamified components. Content was also reframed to specifically target and engage adolescents with mTBI. We describe the usability evaluation of the updated SMART application. Children aged 11-18 years diagnosed with mTBI who were 1 to 6 months post mTBI were recruited to participate in a 1-2-hour usability session in which they thought aloud and responded to targeted usability-related questions during their interaction with the SMART program. After completing the session, participants rated their usability experience using the System Usability Scale (SUS) and rated the overall user-friendliness of the program. Participants' responses during the session were qualitatively coded and analyzed. Six adolescents participated in a usability session (average age = 13.7 years). On the SUS, participants rated the program as highly usable (M = 85.6, SD = 3.24). They also had overwhelmingly positive feedback regarding the content, design and structure of the program. Overall, findings suggest that the redesigned SMART program was usable, acceptable, and relevant to adolescents with mTBI. Based on adolescents' feedback, additional modifications were made before the program undergoes efficacy testing.

Sex-Dependent Pathology in the HPA Axis at a Sub-acute Period After Experimental Traumatic Brain Injury

Over 2.8 million traumatic brain injuries (TBIs) are reported in the United States annually, of which, over 75% are mild TBIs with diffuse axonal injury (DAI) as the primary pathology. TBI instigates a stress response that stimulates the hypothalamic-pituitary-adrenal (HPA) axis concurrently with DAI in brain regions responsible for feedback regulation. While the incidence of affective symptoms is high in both men and women, presentation is more prevalent and severe in women. Few studies have longitudinally evaluated the etiology underlying late-onset affective symptoms after mild TBI and even fewer have included females in the experimental design. In the experimental TBI model employed in this study, evidence of chronic HPA dysregulation has been reported at 2 months post-injury in male rats, with peak neuropathology in other regions of the brain at 7 days post-injury (DPI). We predicted that mechanisms leading to dysregulation of the HPA axis in male and female rats would be most evident at 7 DPI, the sub-acute time point. Young adult age-matched male and naturally cycling female Sprague Dawley rats were subjected to midline fluid percussion injury (mFPI) or sham surgery. Corticotropin releasing hormone, gliosis, and glucocorticoid receptor (GR) levels were evaluated in the hypothalamus and hippocampus, along with baseline plasma adrenocorticotropic hormone (ACTH) and adrenal gland weights. Microglial response in the paraventricular nucleus of the hypothalamus indicated mild neuroinflammation in males compared to sex-matched shams, but not females. Evidence of microglia activation in the dentate gyrus of the hippocampus was robust in both sexes compared with uninjured shams and there was evidence of a significant interaction between sex and injury regarding microglial cell count. GFAP intensity and astrocyte numbers increased as a function of injury, indicative of astrocytosis. GR protein levels were elevated 30% in the hippocampus of females in comparison to sex-matched shams. These data indicate sex-differences in sub-acute pathophysiology following DAI that precede late-onset HPA axis dysregulation. Further understanding of the etiology leading up to late-onset HPA axis dysregulation following DAI could identify targets to stabilize feedback, attenuate symptoms, and improve efficacy of rehabilitation and overall recovery.

Traumatic Brain Injury-Induced Sex-Dependent Changes in Late-Onset Sensory Hypersensitivity and Glutamate Neurotransmission

Women approximate one-third of the annual 2.8 million people in the United States who sustain traumatic brain injury (TBI). Several clinical reports support or refute that menstrual cycle-dependent fluctuations in sex hormones are associated with severity of persisting post-TBI symptoms. Previously, we reported late-onset sensory hypersensitivity to whisker stimulation that corresponded with changes in glutamate neurotransmission at 1-month following diffuse TBI in male rats. Here, we incorporated intact age-matched naturally cycling females into the experimental design while monitoring daily estrous cycle. We hypothesized that sex would not influence late-onset sensory hypersensitivity and associated in vivo amperometric extracellular recordings of glutamate neurotransmission within the behaviorally relevant thalamocortical circuit. At 28 days following midline fluid percussion injury (FPI) or sham surgery, young adult Sprague-Dawley rats were tested for hypersensitivity to whisker stimulation using the whisker nuisance task (WNT). As predicted, both male and female rats showed significantly increased sensory hypersensitivity to whisker stimulation after FPI, with females having an overall decrease in whisker nuisance scores (sex effect), but no injury and sex interaction. In males, FPI increased potassium chloride (KCl)-evoked glutamate overflow in primary somatosensory barrel cortex (S1BF) and ventral posteromedial nucleus of the thalamus (VPM), while in females the FPI effect was discernible only within the VPM. Similar to our previous report, we found the glutamate clearance parameters were not influenced by FPI, while a sex-specific effect was evident with female rats showing a lower uptake rate constant both in S1BF and VPM and longer clearance time (in S1BF) in comparison to male rats. Fluctuations in estrous cycle were evident among brain-injured females with longer diestrus (low circulating hormone) phase of the cycle over 28 days post-TBI. Together, these findings add to growing evidence indicating both similarities and differences between sexes in a chronic response to TBI. A better understanding of the influence of gonadal hormones on behavior, neurotransmission, secondary injury and repair processes after TBI is needed both clinically and translationally, with potential impact on acute treatment, rehabilitation, and symptom management.

The psychological distress and coping styles in the early stages of the 2019 coronavirus disease (COVID-19) epidemic in the general mainland Chinese population: A web-based survey

As the epidemic outbreak of 2019 coronavirus disease (COVID-19), general population may experience psychological distress. Evidence has suggested that negative coping styles may be related to subsequent mental illness. Therefore, we investigate the general population's psychological distress and coping styles in the early stages of the COVID-19 outbreak. A cross-sectional battery of surveys was conducted from February 1-4, 2020. The Kessler 6 psychological distress scale, the simplified coping style questionnaire and a general information questionnaire were administered on-line to a convenience sample of 1599 in China. A multiple linear regression analysis was performed to identify the influence factors of psychological distress. General population's psychological distress were significant differences based on age, marriage, epidemic contact characteristics, concern with media reports, and perceived impacts of the epidemic outbreak (all p <0.001) except gender (p = 0.316). The population with younger age (F = 102.04), unmarried (t = 15.28), with history of visiting Wuhan in the past month (t = -40.86), with history of epidemics occurring in the community (t = -10.25), more concern with media reports (F = 21.84), perceived more impacts of the epidemic outbreak (changes over living situations, F = 331.71; emotional control, F = 1863.07; epidemic-related dreams, F = 1642.78) and negative coping style (t = 37.41) had higher level of psychological distress. Multivariate analysis found that marriage, epidemic contact characteristics, perceived impacts of the epidemic and coping style were the influence factors of psychological distress (all p <0.001). Epidemic of COVID-19 caused high level of psychological distress. The general mainland Chinese population with unmarried, history of visiting Wuhan in the past month, perceived more impacts of the epidemic and negative coping style had higher level of psychological distress in the early stages of COVID-19 epidemic. Psychological interventions should be implemented early, especially for those general population with such characteristics.

The role of mood, post-traumatic stress, post-concussive symptoms and coping on outcome after MTBI in elderly patients

Elderly patients are at increased risk for persistent complaints after mild traumatic brain injury (MTBI). This study aimed to investigate the role of post-concussive symptoms, mood, post-traumatic stress, and coping on functional outcome in elderly with MTBI. Information on mood, post-concussive symptoms, post-traumatic stress, and coping was collected 2 weeks post-injury. Six months post-injury functional outcome was assessed with the Glasgow Outcome Scale Extended. One hundred and sixty-two patients aged ≥ 60 years were included, 55% male, mean age = 71 (±6.2) years. The most frequent cause of injury was falls from standing height (75%). Two weeks post-injury anxiety, depression, and post-traumatic stress were present in 15%, 12%, and 38% of patients, respectively, with 73% reporting post-concussive symptoms. Avoidant coping was the most frequently used coping style. Six months post-injury, 44% showed incomplete recovery. Higher depression scores (OR = 0.87, p = 0.005) and number of post-concussive symptoms (OR = 0.91, p = 0.03) were associated with incomplete recovery. Half of the elderly showed incomplete recovery 6 months after MTBI, with early depression or post-concussive symptoms as important factors. Coping style was not related to outcome. These results underline the need for a different approach in elderly patients, focusing on other predicting factors and fall prevention strategies.

Injury Severity and Depressive Symptoms in a Post-acute Brain Injury Rehabilitation Sample

This study explored the relationship between injury severity and depressive symptoms for treatment-seeking individuals with traumatic brain injury (TBI). The Mayo Classification System was used to classify TBI severity in 72 participants who completed the Patient Health Questionnaire at admission and at dismissal from rehabilitation. Patients with mild TBI reported more depressive symptoms than those with moderate or severe TBI at admission and at dismissal. Although injury severity groups differed by gender composition, gender had no effect on severity of depressive symptoms. All participants reported fewer depressive symptoms at dismissal from rehabilitation, including lower endorsement of dysphoria by discharge. Participants with mild TBI, however, continued to report depressive symptoms of a mild severity at dismissal, with residual problems with anhedonia. These findings underscore the benefit of interdisciplinary post-acute rehabilitation services for persons with TBI of any severity, including those with mild injury.

Pain with traumatic brain injury and psychological disorders

Traumatic brain injury (TBI) is the cause for long-term disability in more than 3 million patients in the US alone, with chronic pain being the most frequently reported complain. To date, predisposing mechanisms for chronic pain in TBI patients are largely unknown. Psychological disorders, including post-traumatic stress disorder, depression and anxiety following TBI are commonly reported comorbidities to post-traumatic pain. Long term consequences can be debilitating and affect quality of life even when the injury is mild. In this review, we present the most commonly reported chronic pain conditions across the spectrum of severity of TBI, mainly focusing on mild TBI. We discuss chronic post- traumatic headaches, widespread pain as well as post-traumatic central pain. We discuss pain in the context of injury severity and military versus civilian populations. We are only starting to understand the biological mechanisms behind post-traumatic pain and associated psychological distress following TBI, with genetic, biochemical and imaging studies pointing to the dopaminergic, neurotrophic factors and the role of Apolipoprotein. Physiological and neurological mechanisms are proposed to partially explain this interaction between post-traumatic pain and psychological distress. Nevertheless, the evidence for the role of structural brain damage remains incomplete and to a large extent debatable, as it is still difficult to establish clear causality between brain trauma and chronic pain. Finally, general aspects of management of chronic pain post-TBI are addressed.

A Multidimensional Approach to Post-concussion Symptoms in Mild Traumatic Brain Injury

Mild traumatic brain injury (mTBI) presents a substantial burden to patients, families, and health care systems. Whereas, recovery can be expected in the majority of patients, a subset continues to report persisting somatic, cognitive, emotional, and/or behavioral problems, generally referred to as post-concussion syndrome (PCS). However, this term has been the subject of debate since the mechanisms underlying post-concussion symptoms and the role of pre- and post-injury-related factors are still poorly understood. We review current evidence and controversies concerning the use of the terms post-concussion symptoms vs. syndrome, its diagnosis, etiology, prevalence, assessment, and treatment in both adults and children. Prevalence rates of post-concussion symptoms vary between 11 and 82%, depending on diagnostic criteria, population and timing of assessment. Post-concussion symptoms are dependent on complex interactions between somatic, psychological, and social factors. Progress in understanding has been hampered by inconsistent classification and variable assessment procedures. There are substantial limitations in research to date, resulting in gaps in our understanding, leading to uncertainty regarding epidemiology, etiology, prognosis, and treatment. Future directions including the identification of potential mechanisms, new imaging techniques, comprehensive, multidisciplinary assessment and treatment options are discussed. Treatment of post-concussion symptoms is highly variable, and primarily directed at symptom relief, rather than at modifying the underlying pathology. Longitudinal studies applying standardized assessment strategies, diagnoses, and evidence-based interventions are required in adult and pediatric mTBI populations to optimize recovery and reduce the substantial socio-economic burden of post-concussion symptoms.

Associations between coping style, illness perceptions and self-reported symptoms after mild traumatic brain injury in prospectively studied pre-morbidly healthy individuals

This study investigated whether coping style and/or illness perceptions are related to the severity of self-reported post-concussion syndrome (PCS) symptoms in the post-acute period after mild traumatic brain injury (mTBI). We hypothesised that reporting of early and late enduring-type PCS symptomatology (self-reported symptoms) would be significantly and negatively associated with: (a) an active "approach" coping style and (b) the belief that the injury would have negative consequences on the respondent's life. Using a prospective observational design we assessed 61 pre-morbidly healthy individuals who were admitted to hospital after an mTBI. Participants were assessed with measures of coping style and illness perception as well as PCS, depressive, anxiety and post-traumatic stress symptomatology. After controlling for current psychological distress, approach coping style significantly and independently predicted the severity of self-reported symptoms for early-type PCS symptomatology, but not late enduring-type PCS symptoms. The extent to which the respondent believed their symptoms were due to the mTBI significantly and independently predicted both early and late enduring-type PCS symptoms. This study indicates that different patterns of coping and illness perceptions are associated with early vs. late enduring types of PCS symptoms; this may have implications for the treatment of post-injury self-reported symptoms.

Unraveling the Biopsychosocial Factors of Fatigue and Sleep Problems After Traumatic Brain Injury: Protocol for a Multicenter Longitudinal Cohort Study

Background

Fatigue and sleep problems are common after a traumatic brain injury (TBI) and are experienced as highly distressing symptoms, playing a significant role in the recovery trajectory, and they can drastically impact the quality of life and societal participation of the patient and their family and friends. However, the etiology and development of these symptoms are still uncertain.

Objective

The aim of this study is to examine the development of fatigue and sleep problems following moderate to severe TBI and to explore the changes in underlying biological (pain, brain damage), psychological (emotional state), and social (support family, participation) factors across time.

Methods

This study is a longitudinal multicenter observational cohort study with 4 measurement points (3, 6, 12, and 18 months postinjury) including subjective questionnaires and cognitive tasks, preceded by 7 nights of actigraphy combined with a sleep diary. Recruitment of 137 moderate to severe TBI patients presenting at emergency and neurology departments or rehabilitation centers across the Netherlands is anticipated. The evolution of fatigue and sleep problems following TBI and their association with possible underlying biological (pain, brain damage), psychological (emotional state), and social (support family, participation) factors will be examined.

Results

Recruitment of participants for this longitudinal cohort study started in October 2017, and the enrollment of participants is ongoing. The first results are expected at the end of 2020.

Conclusions

To the authors’ knowledge, this is the first study that examines the development of both post-TBI fatigue and sleep longitudinally within a biopsychosocial model in moderate to severe TBI using both subjective and objective measures. Identification of modifiable factors such as mood and psychosocial stressors may give direction to the development of interventions for fatigue and sleep problems post-TBI.

Trial Registration

Netherlands Trial Register NTR7162; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=7162 (Archived by WebCite at http://www.webcitation.org/6z3mvNLuy)

International Registered Report Identifier (IRRID)

RR1-10.2196/11295

A study of the influence of cognitive complaints, cognitive performance and symptoms of anxiety and depression on self-efficacy in patients with acquired brain injury

OBJECTIVE:

To examine the relationship between self-efficacy for managing brain injury-specific symptoms and cognitive performance, subjective cognitive complaints and anxiety and depression symptoms in patients with acquired brain injury (ABI).

DESIGN:

Clinical cohort study.

SETTING:

General hospitals, rehabilitation centres.

SUBJECTS:

A total of 122 patients with newly ABI (mean age = 54.4 years (SD, 12.2)) were assessed at discharge home from inpatient neurorehabilitation or at start of outpatient neurorehabilitation after discharge home from acute hospital. Mean time since injury was 14.1 weeks (SD, 8.6).

MAIN MEASURES:

Self-efficacy was measured using the Traumatic Brain Injury (TBI) Self-Efficacy Questionnaire (SEsx), mean score = 82.9 (SD, 21.8). Objective cognitive performance was measured with the Symbol Digit Modalities Test (SDMT), mean z-score = -1.36 (SD, 1.31). Anxiety and depression symptoms were measured with the Hospital Anxiety and Depression Scale (HADS), cognitive complaints with the self-rating form of the Dysexecutive Questionnaire (DEX-P).

RESULTS:

Higher levels of subjective cognitive complaints and higher levels of anxiety and depression symptoms were significantly associated with lower self-efficacy (β = -0.35; P = .001 and β =-0.43; P < .001, respectively). Objective cognitive performance was not significantly associated with self-efficacy (β = 0.04, P = .53). DEX-P scores accounted for 42% and HADS scores for 7% of the total 57% variance explained. Objective cognitive performance did not correlate significantly with subjective cognitive complaints (r = -.13, P = .16).

CONCLUSION:

Control over interfering emotions and mastery over brain injury-associated symptoms seems important in the development of self-efficacy for managing brain injury-specific symptoms.

Adversity and Resilience Are Associated with Outcome after Mild Traumatic Brain Injury in Military Service Members

The objective of this study was to assess the associations between resilience, adversity, post-concussion symptoms, and post-traumatic stress symptom reporting after mild traumatic brain injury (mTBI). We hypothesized that resilience would be associated with less symptom reporting, and adversity would be associated with greater symptom reporting. This was a cross-sectional study of retrospective data collected for an ongoing TBI repository. United States military service members who screened positive for mTBI during a primary care visit completed the Trauma History Screen (THS), Connor-Davidson Resilience Scale (CD-RISC), Neurobehavioral Symptom Inventory (NSI), and post-traumatic stress disorder (PTSD) Checklist-Civilian Version (PCL-C). Data collected from February 2015 to August 2016 were used for the present study. Only participants with complete data for the above measures were included, yielding a sample size of 165 participants. Adversity (THS) and resilience (CD-RISC) scores were each correlated significantly with post-concussion (NSI) and traumatic stress (PCL-C) total and subscale scores in the hypothesized direction. Interactions between adversity and resilience were absent for all measures except the NSI sensory subscale. Four traumatic event types were significantly associated positively with most NSI and PCL-C total and subscale scores, but the age at which traumatic events were first experienced showed few and mixed significant associations. In conclusion, resilience and adversity were significantly associated with symptom endorsement after mTBI. Screening for cumulative adversity may identify individuals at greater risk of developing persistent post-concussion symptoms and/or PTSD, and interventions that increase resilience may reduce symptom severity.

Evaluating anxiety and depression symptoms in children and adolescents with prior mild traumatic brain injury: Agreement between methods and respondents

Psychological functioning can be adversely impacted after a mild traumatic brain injury (mTBI) and may be a potential target for intervention. Despite the use of symptom ratings or structured diagnostic interview to assess long-term anxiety and depression symptoms in children and adolescents post-injury, no known studies have considered the agreement between different assessment methods and between respondents. The objectives of this study were to investigate the agreement between symptom ratings and structured diagnostic interview and between children and parents' symptom reporting. Participants (N = 33; 9-18 years old) were recruited from the Emergency Department and assessed on average 22.8 months (SD = 5.6) after their mTBI. Anxiety and depression symptoms were evaluated via subscales of a questionnaire (Behavior Assessment System for Children) and parts of a computerized structured diagnostic interview (generalized anxiety disorder and major depressive episode; Diagnostic Interview Schedule for Children - C-DISC-IV) administered individually to children and their parents. Results showed that the inter-method agreement to identify high levels of anxiety and depression was moderate to perfect in children while it was lower in parents. Although a similar percentage of participants with elevated anxiety or depression were identified by both children and parents, the agreement between youth and parents was variable, ranging from poor to good for anxiety and poor to moderate for depression. These results highlight the importance of collecting youth and parents' reports of anxiety and depression symptoms and considering potential discrepancies between informants' answers.

Subjective complaints after acquired brain injury: presentation of the Brain Injury Complaint Questionnaire (BICoQ)

The objective of the present study was to present a new complaint questionnaire designed to assess a wide range of difficulties commonly reported by patients with acquired brain injury. Patients (n =  619) had been referred to a community re-entry service at a chronic stage after brain injury, mainly traumatic brain injury (TBI). The Brain Injury Complaint Questionnaire (BICoQ) includes 25 questions in the following domains: cognition, behavior, fatigue and sleep, mood, and somatic problems. A self and a proxy questionnaire were given. An additional question was given to the relative, about the patient's awareness of his difficulties. The questionnaires had a good internal coherence, as measured with Cronbach's alpha. The most frequent complaints were, in decreasing order, mental slowness, memory troubles, fatigue, concentration difficulties, anxiety, and dual tasking problems. Principal component analysis with varimax rotation yielded six underlying factors explaining 50.5% of total variance: somatic concerns, cognition, and lack of drive, lack of control, psycholinguistic disorders, mood, and mental fatigue/slowness. About 52% of patients reported fewer complaints than their proxy, suggesting lack of awareness. The total complaint scores were not significantly correlated with any injury severity measure, but were significantly correlated with disability and poorer quality of life (Note: only factor 2 [cognition/lack of drive] was significantly related to disability.) The BICoQ is a simple scale that can be used in addition to traditional clinical and cognitive assessment measures, and to assess awareness of everyday life problems.

Do Mild Traumatic Brain Injury Severity Sub-classification Systems Help to Identify People Who Go on to Experience Long-Term Symptoms?

Objective: To identify the systems available to sub-classify mild traumatic brain injury (TBI) and to determine their utility in predicting 1-year outcome.

Methods: A systematic review to identify mild-TBI sub-classification systems was conducted until March 2016. The identified systems were applied to a cohort ofN= 290 adults who had experienced a mild-TBI, and who had been assessed for post-concussion symptoms 1-year post injury. ANOVAs and regression models were used to determine whether each sub-classification system could distinguish between outcomes and to explore their contribution to explaining variance in post-concussion symptoms 1-year post injury.

Results: Nineteen sub-classification systems for mild-TBI met the inclusion criteria for this review. The Saal (1991) classification system significantly differentiated the experience of post-concussion symptoms in our cohort 1-year post injury (F= 2.39,p= 0.05). However, the findings did not remain significant following correction for multiple comparisons and inclusion of socio-demographic and contextual factors in the regression model.

Conclusions: Current sub-classification systems fail to explain much of the variance in post-concussion symptoms 1 year following mild-TBI. Further research is needed to identify the factors (including socio-demographic and contextual factors) to determine, who may be at risk of developing persistent post-concussion symptoms.

Outcomes of a community-based treatment programme for people with acquired brain injury in the chronic phase: a pilot study

The objective of the study was to evaluate the outcomes of Brainz, a low intensity community-based treatment programme for people with acquired brain injury (ABI). Participants were 62 people with sustained ABI (5.2 years post-injury, SD = 4.5) and 35 family caregivers. Participants attended two to five cognitive and physical group modules and received two hours of individual home treatment every two weeks. Primary outcomes for people with ABI were participation, perceived difficulties in daily life and need of care, level of goal attainment, and self-esteem. Primary family caregiver outcome was perceived burden of care. Attrition rate of people with ABI was 24% (n = 15), and of family caregivers was 31% (n = 11). People with ABI were more satisfied with the level of their participation after completing Brainz (p < .01), but showed no change in participation frequency or in restrictions (both ps > .01). They perceived fewer difficulties in daily life and less need of care (both ps < .01). Also, in two cognitive modules people improved on their goal achievement (p < .01). However, their self-esteem was reduced (p < .01). Caregiver burden was reduced (p < .01). This study has provided preliminary evidence of the effectiveness of a combined group-based clinical and individual home-based treatment programme, but more research is needed, preferably in larger controlled studies.