Post-traumatic and emotional symptoms in different subgroups of patients with mild head injury

A Double-Blind Placebo-Controlled, Randomized Trial of Divalproex Sodium for Posttraumatic Irritability Greater Than 1 Year After Mild to Moderate Traumatic Brain Injury

OBJECTIVE

Posttraumatic irritability after traumatic brain injury (TBI) may become a chronic problem and contribute to impaired everyday function, either alone or in combination with alcohol use disorder. The authors hypothesized that divalproex sodium (VPA) would improve posttraumatic irritability and result in lessened alcohol use.

METHODS

This randomized, placebo-controlled double-blind clinical trial recruited participants with an index TBI occurring 1 or more years prior to enrollment, a history of alcohol use disorder, and posttraumatic irritability corroborated by a knowledgeable informant. An 8-item subset of the Agitated Behavior Scale served as the primary outcome measure of VPA efficacy. Doses of VPA were titrated to standard serum concentrations of 50 µg/ml to 100 µg/ml.

RESULTS

Forty-eight persons completed this clinical trial (VPA, N=22; placebo, N=26). At baseline, participants rated their posttraumatic irritability as less severe than did their informants (p<0.05). During the trial, informants reported significant and sustained reduction of posttraumatic irritability (p=0.03) in the study participants. Biweekly averages during drug exposure confirmed this (p<0.03, Cohen's d=0.44). Treatment efficacy was not related to measures of anxiety, posttraumatic stress disorder, sedation, or veteran versus nonveteran status. Alcohol use did not change as a result of treatment. There were no serious adverse events.

CONCLUSIONS

This study demonstrated an effect of VPA on posttraumatic irritability, and VPA was well tolerated. Further definition of treatment efficacy and safety requires a large-scale multisite trial, using a randomized, double-blind placebo-controlled design.

Brain Connectivity Changes in Post-Concussion Syndrome as the Neural Substrate of a Heterogeneous Syndrome

BACKGROUND

Post-concussion syndrome (PCS) or persistent symptoms of concussion refers to a constellation of symptoms that persist for weeks and months after a concussion. To better capture the heterogeneity of the symptoms of patients with post-concussion syndrome, we aimed to separate patients into clinical subtypes based on brain connectivity changes.

METHODS

Subject-specific structural and functional connectomes were created based on Diffusion Weighted and Resting State Functional Magnetic Resonance Imaging, respectively. Following an informed dimensionality reduction, a gaussian mixture model was used on patient specific structural and functional connectivity matrices to find potential patient clusters. For validation, the resulting patient subtypes were compared in terms of cognitive, neuropsychiatric, and post-concussive symptom differences.

RESULTS

Multimodal analyses of brain connectivity were predictive of behavioural outcomes. Our modelling revealed 2 patient subtypes; mild and severe. The severe group showed significantly higher levels of depression, anxiety, aggression, and a greater number of symptoms than the mild patient subgroup.

CONCLUSION

This study suggests that structural and functional connectivity changes together can help us better understand the symptom severity and neuropsychiatric profiles of patients with post-concussion syndrome. This work allows us to move towards precision medicine in concussions and provides a novel machine learning approach that can be applicable to other heterogeneous conditions.

Diffusion and functional MRI findings and their relationship to behaviour in postconcussion syndrome: a scoping review

Postconcussion syndrome (PCS) is a term attributed to the constellation of symptoms that fail to recover after a concussion. PCS is associated with a variety of symptoms such as headaches, concentration deficits, fatigue, depression and anxiety that have an enormous impact on patients' lives. There is currently no diagnostic biomarker for PCS. There have been attempts at identifying structural and functional brain changes in patients with PCS, using diffusion tensor imaging (DTI) and functional MRI (fMRI), respectively, and relate them to specific PCS symptoms. In this scoping review, we appraised, synthesised and summarised all empirical studies that (1) investigated structural or functional brain changes in PCS using DTI or fMRI, respectively, and (2) assessed behavioural alterations in patients with PCS. We performed a literature search in MEDLINE (Ovid), Embase (Ovid) and PsycINFO (Ovid) for primary research articles published up to February 2020. We identified 8306 articles and included 45 articles that investigated the relationship between DTI and fMRI parameters and behavioural changes in patients with PCS: 20 diffusion, 20 fMRI studies and 5 papers with both modalities. Most frequently studied structures were the corpus callosum, superior longitudinal fasciculus in diffusion and the dorsolateral prefrontal cortex and default mode network in the fMRI literature. Although some white matter and fMRI changes were correlated with cognitive or neuropsychiatric symptoms, there were no consistent, converging findings on the relationship between neuroimaging abnormalities and behavioural changes which could be largely due to the complex and heterogeneous presentation of PCS. Furthermore, the heterogeneity of symptoms in PCS may preclude discovery of one biomarker for all patients. Further research should take advantage of multimodal neuroimaging to better understand the brain-behaviour relationship, with a focus on individual differences rather than on group comparisons.

Predicting Concussion Outcome by Integrating Finite Element Modeling and Network Analysis

Concussion is a significant public health problem affecting 1.6-2.4 million Americans annually. An alternative to reducing the burden of concussion is to reduce its incidence with improved protective equipment and injury mitigation systems. Finite element (FE) models of the brain response to blunt trauma are often used to estimate injury potential and can lead to improved helmet designs. However, these models have yet to incorporate how the patterns of brain connectivity disruption after impact affects the relay of information in the injured brain. Furthermore, FE brain models typically do not consider the differences in individual brain structural connectivities and their purported role in concussion risk. Here, we use graph theory techniques to integrate brain deformations predicted from FE modeling with measurements of network efficiency to identify brain regions whose connectivity characteristics may influence concussion risk. We computed maximum principal strain in 129 brain regions using head kinematics measured from 53 professional football impact reconstructions that included concussive and non-concussive cases. In parallel, using diffusion spectrum imaging data from 30 healthy subjects, we simulated structural lesioning of each of the same 129 brain regions. We simulated lesioning by removing each region one at a time along with all its connections. In turn, we computed the resultant change in global efficiency to identify regions important for network communication. We found that brain regions that deformed the most during an impact did not overlap with regions most important for network communication (Pearson's correlation, ρ = 0.07; p = 0.45). Despite this dissimilarity, we found that predicting concussion incidence was equally accurate when considering either areas of high strain or of high importance to global efficiency. Interestingly, accuracy for concussion prediction varied considerably across the 30 healthy connectomes. These results suggest that individual network structure is an important confounding variable in concussion prediction and that further investigation of its role may improve concussion prediction and lead to the development of more effective protective equipment.

Stress and lasting symptoms following injury: Results from a 4-month cohort of trauma patients recruited at the emergency department

INTRODUCTION

Recent research suggests that up to 20% of minor trauma patients admitted to the emergency department (ED) will suffer from non-specific chronic conditions over the subsequent several months. Thus, the present study assessed the correlates of symptoms that persisted at 4 months after an ED visit and, in particular, evaluated the associations between these symptoms and self-reported stress levels at ED admission and discharge.

METHOD

This study was a prospective observational investigation conducted in the ED of Bordeaux University Hospital that included patients admitted for minor trauma. All participants were contacted by phone 4 months after presentation at the ED to assess the occurrence of post-concussion-like symptoms (PCLS).

RESULTS

A total of 193 patients completed the follow-up assessment at 4 months; 5.2% of the participants suffered from post-traumatic stress disorder (PTSD) and 24.5% suffered from PCLS. A multivariate analysis revealed an association between PCLS and stress level at discharge from the ED (odds ratios [OR]: 2.85, 95% confidence interval [CI]: 1.10-7.40).

CONCLUSIONS

The risk of PCLS at 4 months after an ED visit for a minor injury increased in association with the level of stress at discharge from the ED. These results may improve the quality of life for the millions of patients who experience a stressful injury event every year.

A review of research efforts to address the 2008 ACEP guideline for mild traumatic brain injury

BACKGROUND

The objective of this study was to evaluate the temporal relationship between clinical practice guideline development and subsequent research performed, with the goal of providing more data on areas of sparse evidence that serve to underlie guideline recommendations. We aimed to assess the quality of current research efforts to address the American College of Emergency Physicians guideline and to provide suggestions for future research of mild traumatic brain injury.

METHODS

We identified clinical practice guideline recommendations with low levels of underlying evidence and searched ClinicalTrials.gov and the World Health Organization's International Clinical Trial Registry Portal to determine whether subsequent research has reflected an effort to address guideline recommendations.

RESULTS

Few currently registered clinical trials attempt to focus on clinical practice guideline recommendations where the basis of evidence is weak, and even fewer might benefit future iterations of the guideline due to multiple problems in study design and reporting.

CONCLUSIONS

The amount of research dedicated to investigation of mild traumatic brain injury continues to be sparse and of poor quality. Study results should always be posted, even if the null hypothesis is confirmed. Efforts to improve the evidence base of a guideline should be realized by designing studies that directly assess and speak to the questions posed by guideline authors.

Concussion Alters the Functional Brain Processes of Visual Attention and Working Memory

Millions of North Americans sustain a concussion or a mild traumatic brain injury annually, and are at risk of cognitive, emotional, and physical sequelae. Although functional MRI (fMRI) studies have provided an initial framework for examining functional deficits induced by concussion, particularly working memory and attention, the temporal dynamics underlying these deficits are not well understood. We used magnetoencephalography (MEG), a modality with millisecond temporal resolution, in conjunction with a 1-back visual working memory (VWM) paradigm using scenes from everyday life to characterize spatiotemporal functional differences at specific VWM stages, in adults had had or had not had a recent concussion. MEG source-level differences between groups were determined by whole-brain analyses during encoding and recognition phases. Despite comparable behavioral performance, abnormal hypo- and hyperactivation patterns were found in brain areas involving frontoparietal, ventral occipitotemporal, temporal, and subcortical areas in concussed patients. These patterns and their timing varied as a function of VWM stagewise processing, linked to early attentional control, visuoperceptual scene processing, and VWM maintenance and retrieval processes. Parietal hypoactivation, starting at 60 ms during encoding, was correlated with symptom severity, possibly linked to impaired top-down attentional processing. Hyperactivation in the scene-selective occipitotemporal areas, the medial temporal complex, specifically the right hippocampus and orbitofrontal areas during encoding and/or recognition, lead us to posit inefficient but compensatory visuoperceptual, relational, and retrieval processing. Although injuries sustained after the concussion were considered "mild," these data suggest that they can have prolonged effects on early attentional and VWM processes.

Brain contusion as the main risk factor of memory or emotional complaints in chronic complicated mild traumatic brain injury

OBJECTIVE

To investigate the risk factors for memory or emotional complaints in patients with complicated mild traumatic brain injury (mTBI).

METHODS

Retrospective analysis of medical records was conducted by physicians in a teaching hospital in Southern Taiwan, and complicated mTBI had been identified by means of computed tomography. Psychological complaints, including problems with memory and emotions, were collected by structured telephone interviews, 10-15 minutes long, and were held with subjects who agreed to participate in our study. Among 327 patients who were injured for more than two years, 190 agreed to join this study (mean age: 41.6 years; male: 60.5%; stably employed: 50.0%). We used demographic data and neurological factors to predict memory or emotional complaints without muscle power or response speed (MEMR) complaints.

RESULTS

Only the presence or absence of cerebral contusions predicted memory or emotional complaints without MEMR complaints in different employed status, and the odds ratio was 4.82-13.50 times higher for those with cerebral contusions than for those without.

CONCLUSIONS

Cerebral contusions were the primary risk factor for MEMR complaints in chronic complicated mTBI. Early preventive psychological intervention might be necessary for patients with complicated mTBI and cerebral contusions.

Reduced power spectra of heart rate variability are correlated with anxiety in patients with mild traumatic brain injury

Anxiety is one of the most frequently diagnosed emotional disorders after a mild traumatic brain injury (mTBI); however, predictors of anxiety after an mTBI remain uncertain. Recent research indicated that anxiety is associated with abnormalities in the autonomic nervous system (ANS) which can be evaluated by a power spectral analysis of heart rate variability (HRV). In this study, we investigated whether a frequency-domain analysis of HRV could correlate with the occurrence of anxiety in mTBI patients. We recruited 165 Taiwanese patients diagnosed with an mTBI and 82 volunteer healthy controls from three affiliated hospitals of Taipei Medical University during 2010-2014. The Beck Anxiety Inventory (BAI) was assessed at the 1st, 6th, and 12th weeks. We found that mTBI patients were more vulnerable to anxiety compared to healthy controls. The power spectral density of HRV was significantly lower in mTBI patients than in healthy controls. A correlation analysis indicated that anxiety was negatively significantly correlated with low- and high-frequency power at the 6th week. Our study suggests the clinical usefulness of HRV as a potential noninvasive tool for evaluating later anxiety in mTBI patients.

Frequency of Factors that Complicate the Identification of Mild Traumatic Brain Injury in Level I Trauma Center Patients

AIM

Determine the frequency of factors that complicate identification of mild traumatic brain injury (mTBI) in emergency department (ED) patients.

SETTING

Chart review.

MATERIALS & METHODS

Records of 3,042 patients (age 18-45) exposed to a potential mechanism of mTBI were reviewed for five common complicating factors and signs of mTBI.

RESULTS

Most patients (65.1%) had at least one complicating factor: given narcotics in the ED (43.7%), on psychotropic medication (18.4%), psychiatric diagnosis (15.3%), alcohol consumption near time of admission (14.2%), and pre-admission narcotic prescription (8.9%).

CONCLUSION

Our findings highlight the frequency of these confounding factors in this population. Future research should identify how these factors interact with performance on assessment measures to improve evidence-based mTBI assessment in this population.

Early dysautonomia detected by heart rate variability predicts late depression in female patients following mild traumatic brain injury

Depression is one of the frequent complications following a mild traumatic brain injury (mTBI). Recent research indicated that abnormalities in the autonomic nervous system (ANS) can be evaluated by a noninvasive power spectral analysis of the heart rate variability (HRV). In this study, we investigated whether a frequency-domain analysis of HRV was correlated with late depression in mTBI patients. In total, 181 patients diagnosed with mTBI and 83 volunteers as healthy controls were recruited in 2010-2014. Beck Depression Inventory (BDI) scores were used to evaluate depression in the 1st week of assessment and at 1.5-, 3-, 6-, 12-, and 18-month follow-ups. Correlation and logistic regression analyses of the 1st week HRV parameters with BDI scores at 18 months were performed in individual female mTBI patients. Female mTBI patients were more vulnerable to depression accompanied by reduced HRV compared to healthy controls. Over time, depression was aggravated in female mTBI patients but was alleviated in male mTBI patients. A significantly lower parasympathetic proportion of the ANS was noted at 18 months with respect to the 1st week in female mTBI patients. In addition, depression in female mTBI patients at 18 months after injury was significantly correlated with a decrease in the parasympathetic proportion of the ANS in the 1st week (ρ = -0.411; p < .05). Dysautonomia resulted in higher risks of depression in female mTBI patients. We concluded that early dysautonomia following an mTBI contributes to late depression in female mTBI patients.

Sustained outcomes following mild traumatic brain injury: results of a five-emergency department longitudinal study

OBJECTIVE

To report on the occurrence of sustained outcomes including post-concussion symptoms, health services used and indicators of social disruption following a mild traumatic brain injury (MTBI).

RESEARCH DESIGN

A dual cohort comparing MTBI Emergency Department (ED) patients and a comparison group of non-head injured ED patients.

METHODS AND PROCEDURES

The outcomes measures employed were the Rivermead Post-Concussion Symptoms Questionnaire (RPQ) and indicators of health services used and social disruption all recorded at the ED and at 3 and 6 months post-ED discharge. 'Sustained' meant a positive response to these measures at 3 and 6 months.

MAIN OUTCOMES AND RESULTS

Reasonable follow-up success was achieved at 3 and 6 months and the cohorts were alike on all demographic descriptors. RPQ average score and symptom occurrence were far more frequent among MTBI patients than for the comparison cohort from 3 to 6 months. The use of health services and indicators of social disruption were also more frequent among MTBI post-discharge patients.

CONCLUSIONS

These findings argue that some with an MTBI suffer real complaints and they are sustained from 3 to at least 6 months. More effort should be given toward specificity of these symptoms from those reported by members of the comparison group.

Emotional and behavioral dyscontrol after traumatic brain injury

Emotional and behavioral dyscontrol are relatively common neuropsychiatric sequelae of traumatic brain injury and present substantial challenges to recovery and community participation. Among the most problematic and functionally disruptive of these types of behaviors are pathologic laughing and crying, affective lability, irritability, disinhibition, and aggression. Managing these problems effectively requires an understanding of their phenomenology, epidemiology, and clinical evaluation. This article reviews these issues and provides clinicians with brief and practical suggestions for the management of emotional and behavioral dyscontrol.

Does age affect symptom recovery after sports-related concussion? A study of high school and college athletes

OBJECT

Sport-related concussions (SRCs) in high school and college athletes represent a significant public health concern. Research suggests that younger athletes fare worse symptomatically than older athletes after an SRC. Using reliable change index (RCI) methodology, the authors conducted a study to determine if there are age-related differences in number, severity, and resolution of postconcussion symptoms.

METHODS

Between 2009 and 2011, baseline measures of neurocognitive functions and symptoms in high school and college athletes were entered into a regional database. Seven hundred forty of these athletes later sustained an SRC. Ninety-two athletes in the 13- to 16-year-old group and 92 athletes in the 18- to 22-year-old group were matched for number of prior concussions, sex, biopsychosocial variables, and days to first postconcussion testing and symptom assessment. A nonparametric Mann-Whitney U-test was used to compare the severity of each of 22 symptoms comprising the Total Symptom Scale (TSS) at baseline and first postconcussion test. To obtain a family-wise p value of 0.05 for each test, the significance level for each symptom comparison was set at an alpha of 0.05/22 = 0.0023. The number of days to return to baseline TSS score was compared using the RCI methodology, set at the 80% confidence interval, equal to a change in raw score of 9.18 points on the TSS.

RESULTS

There was no statistically significant difference in symptom presence, symptom severity, and total symptoms between the age groups at baseline or at postconcussion testing. There was no statistically significant difference in return to baseline symptom scores between the age groups.

CONCLUSIONS

Using RCI methodology, there was no statistically significant difference between younger and older athletes in return to baseline symptoms postconcussion.

Meta-analytic methods and the importance of non-TBI factors related to outcome in mild traumatic brain injury: response to Bigler et al. (2013)

Bigler et al. (2013, The Clinical Neuropsychologist) contend that weak methodology and poor quality of the studies comprising our recent meta-analysis led us to miss detecting a subgroup of mild traumatic brain injury (mTBI) characterized by persisting symptomatic complaint and positive biomarkers for neurological damage. Our computation of non-significant Q, tau(2), and I(2) statistics contradicts the existence of a subgroup of mTBI with poor outcome, or variation in effect size as a function of quality of research design. Consistent with this conclusion, the largest single contributor to our meta-analysis, Dikmen, Machamer, Winn, and Temkin (1995, Neuropsychology, 9, 80) yielded an effect size, -0.02, that was smaller than our overall effect size of -0.07 despite using the most liberal definition of mTBI: loss of consciousness less than 1 hour, with no exclusion of subjects who had positive CT scans. The evidence is weak for biomarkers of mTBI, such as diffusion tensor imaging and for demonstrable neuropathology in uncomplicated mTBI. Postconcussive symptoms, and reduced neuropsychological test scores are not specific to mTBI but can result from pre-existing psychosocial and psychiatric problems, expectancy effects and diagnosis threat. Moreover, neuropsychological impairment is seen in a variety of primary psychiatric disorders, which themselves are predictive of persistent complaints following mTBI. We urge use of prospective studies with orthopedic trauma controls in future investigations of mTBI to control for these confounding factors.

Characteristics of acute posttraumatic headache following mild head injury

BACKGROUND

To examine the prevalence and characteristics of acute posttraumatic headache (APTH) attributed to mild head injury within a prospective, observational study design.

METHODS

We recruited 100 patients with acute mild head injury as defined in the International Classification of Headache Disorders, 2nd Edition (ICHD-2) presenting to the department of trauma surgery at the Medical University of Vienna. Patients underwent a detailed telephone interview between days 7 and 10 and between days 90 and 100 after the injury.

RESULTS

The prevalence of APTH was 66%. APTH had occurred within 24 hours after the trauma in 78% and lasted for a median of 3.0 days. Headache was unilateral in 45%. Aggravation by physical activity, nausea and photo-/phonophobia was present in 49%, 42% and 55%, respectively. The prevalence of APTH was related to conditions of chronic pain (excluding headache), pre-existing episodic headache, number of posttraumatic symptoms, anxiety and depression. At follow-up at 90-100 days, posttraumatic headache had abated in all patients.

CONCLUSIONS

APTH attributed to mild head injury is a common but self-limiting condition frequently showing migrainous features. Participants with chronic pain other than headache, pre-existing headache and affective disorders are at higher risk of developing APTH. None of the patients developed chronic posttraumatic headache.

Gender differences in self reported long term outcomes following moderate to severe traumatic brain injury

BACKGROUND

The majority of research on health outcomes after a traumatic brain injury is focused on male participants. Information examining gender differences in health outcomes post traumatic brain injury is limited. The purpose of this study was to investigate gender differences in symptoms reported after a traumatic brain injury and to examine the degree to which these symptoms are problematic in daily functioning.

METHODS

This is a secondary data analysis of a retrospective cohort study of 306 individuals who sustained a moderate to severe traumatic brain injury 8 to 24 years ago. Data were collected using the Problem Checklist (PCL) from the Head Injury Family Interview (HIFI). Using Bonferroni correction, group differences between women and men were explored using Chi-square and Wilcoxon analysis.

RESULTS

Chi-square analysis by gender revealed that significantly more men reported difficulty setting realistic goals and restlessness whereas significantly more women reported headaches, dizziness and loss of confidence. Wilcoxon analysis by gender revealed that men reported sensitivity to noise and sleep disturbances as significantly more problematic than women, whereas for women, lack of initiative and needing supervision were significantly more problematic in daily functioning.

CONCLUSION

This study provides insight into gender differences on outcomes after traumatic brain injury. There are significant differences between problems reported by men compared to women. This insight may facilitate health service planners and clinicians when developing programs for individuals with brain injury.

A meta-analytic review of the emotional symptoms associated with mild traumatic brain injury

Given the prevalence of mild traumatic brain injury (mTBI) and enduring subjective complaints known as postconcussion symptoms (PCS), it is important to investigate the nature and extent of these difficulties. This study used meta-analytic techniques to integrate the available information on the emotional symptoms associated with mTBI. Small effect sizes were found across all domains (depression, anxiety, coping, and psychosocial disability); however, significance depended upon the weighting method employed. The results indicate that mTBI had a small to negligible effect on emotional symptom reporting. This has implications for the etiology of PCS, the delivery of therapeutic interventions, and medico-legal disputations.

The neurovegetative complaints questionnaire in the Maastricht aging study: Psychometric properties and normative data

OBJECTIVES

Neurovegetative and somatic symptoms (such as headaches, heart palpitations and dizziness) have a high prevalence. These symptoms are often indicative for 'masked depression' or 'depression without sadness', especially in older adults. At present, no instrument exists which enables the assessment of these symptoms. This study presents a questionnaire which assesses neurovegetative and somatic complaints, as well as reactive emotional complaints: the 'Neurovegetative Complaints Questionnaire' (NCQ).

METHODS

The factor structure, internal consistency and validity of the NCQ were evaluated in a very large sample of 1105 healthy subjects aged 24-81 years from the Maastricht Aging Study. The effects of age, sex and educational level on the NCQ measures were established to provide demographically corrected normative data.

RESULTS

Two constructs underlay the responses to the NCQ items, i.e. the neurovegetative/somatic and reactive/emotional complaints factors (eigenvalues were 4.63 and 1.65, respectively, 33.0% of the variance was explained, Pearson's r between both factors equalled 0.448). Internal consistency of both scales was acceptable (i.e. Cronbach's alpha = 0.74 and 0.71, respectively) and convergent validity was sufficient (Pearson's r = |0.387 - 0.499|). Females and older participants were characterised by more neurovegetative/somatic and reactive/emotional complaints compared to males and younger people. Demographically corrected regression-based norms were provided for use in research and clinical settings.

CONCLUSIONS

The NCQ is a psychometrically sound questionnaire that is specifically aimed at assessing neurovegetative/somatic and reactive/emotional complaints, symptoms that often are indicative for a 'masked depression'.

The relationship between psychological distress and baseline sports-related concussion testing

OBJECTIVE

This study examined the effect of psychological distress on neurocognitive performance measured during baseline concussion testing.

DESIGN

Archival data were utilized to examine correlations between personality testing and computerized baseline concussion testing. Significantly correlated personality measures were entered into linear regression analyses, predicting baseline concussion testing performance. Suicidal ideation was examined categorically.

SETTING

Athletes underwent testing and screening at a university athletic training facility.

PARTICIPANTS

Participants included 47 collegiate football players 17 to 19 years old, the majority of whom were in their first year of college.

INTERVENTIONS

Participants were administered the Concussion Resolution Index (CRI), an internet-based neurocognitive test designed to monitor and manage both at-risk and concussed athletes. Participants took the Personality Assessment Inventory (PAI), a self-administered inventory designed to measure clinical syndromes, treatment considerations, and interpersonal style.

MAIN OUTCOME MEASURES

Scales and subscales from the PAI were utilized to determine the influence psychological distress had on the CRI indices: simple reaction time, complex reaction time, and processing speed.

RESULTS

Analyses revealed several significant correlations among aspects of somatic concern, depression, anxiety, substance abuse, and suicidal ideation and CRI performance, each with at least a moderate effect. When entered into a linear regression, the block of combined psychological symptoms accounted for a significant amount of baseline CRI performance, with moderate to large effects (r = 0.23-0.30). When examined categorically, participants with suicidal ideation showed significantly slower simple reaction time and complex reaction time, with a similar trend on processing speed.

CONCLUSIONS

Given the possibility of obscured concussion deficits after injury, implications for premature return to play, and the need to target psychological distress outright, these findings heighten the clinical importance of screening for psychological distress during baseline and post-injury concussion evaluations.

Preinjury factors and 3-month outcomes following emergency department diagnosis of mild traumatic brain injury

OBJECTIVE

To investigate the sequelae of mild traumatic brain injury (MTBI) by comparing selected outcomes of emergency department-diagnosed patients with mild head injuries to those with non-head injuries.

SETTING

Five emergency departments in southern California.

PARTICIPANTS

Two cohorts, one with MTBI (n = 689 at initial assessment) and another with non-head injuries (n = 1318).

MAIN MEASURES

Rivermead Post-Concussion Symptoms Questionnaire and Pittsburgh Sleep Quality Index at 3 months postinjury.

RESULTS

Postconcussion symptom rates and summary Rivermead Post-Concussion Symptoms Questionnaire scores were significantly higher for persons with MTBI than for the comparison cohort. Women reported significantly more symptoms than men. Complaints about sleep quality overall (and also sleep latency and daytime dysfunction subcomponents) were significantly more frequent among those with MTBI.

CONCLUSION

Patients with MTBI have significantly more negative outcomes than patients in the comparison cohort and should be clinically managed with these prevalent outcomes in mind. Further study of follow-up medical management and the development of treatment guidelines for this group of patients are both 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 relationship between gender and postconcussion symptoms after sport-related mild traumatic brain injury

OBJECTIVE

The authors sought to define the relationship between gender and postconcussion symptoms (PCSx) at 3 months after sport-related mild traumatic brain injury (mTBI) and, further, to examine whether age (minors vs. adults), source of PCSx reporting (self-reported vs. proxy), previous head injury or loss of consciousness, or the sport type in which the mTBI was incurred explain any observed gender differences in PCSx.

DESIGN

Prospective nested cohort study.

SETTING

Regional trauma center emergency department.

PATIENTS

A total of 260 patients who presented with sport-related mTBI, as defined by American Congress of Rehabilitation Medicine criteria, began the study. The participants who lacked litigation concerning the mTBI and had participated in the follow-up assessment completed the study (n = 215).

ASSESSMENT OF RISK FACTORS

Self, proxy, and interviewer report of age, gender, previous head injury or loss of consciousness, and sport in which injury was sustained.

MAIN OUTCOME MEASUREMENTS

Rivermead Post Concussion Symptoms Questionnaire (RPQ).

RESULTS

Adult females are at greater risk for elevated RPQ scores (odds ratio [OR] = 2.89, 95% confidence interval [95% CI] = 1.25-6.71; P = .013) but not female minors (OR = 0.87, 95% CI = 0.45-1.71]; P = .695), as compared with male subjects. Adjustment for empirically identified confounders in each age group revealed persisting elevated risk for adult females (OR = 2.57, 95% CI = 1.09-6.08; P = .031), but not minor females (OR = 1.07, 95% CI = 0.52-2.19, P = .852). The risk associated with female gender in adults could not be explained by characteristics of the sports, such as helmeted versus not, or contact versus no contact, in which women incurred mTBIs. No sport characteristics were associated with increased risk of PCSx after mTBI.

CONCLUSIONS

Adult females, but not female minors, are at increased risk for PCSx after sport-related mTBI as compared with male patients. This increased risk cannot be explained by self-report, rather than proxy report, of symptoms, previous head injury or loss of consciousness, age, or sport characteristics. Further research is needed to elucidate the processes of age-differential recovery from mild brain injury in women and on how to most effectively incorporate appropriate follow-up after emergency department evaluation.

Applicability of neural reserve theory in mild traumatic brain injury

OBJECTIVE

The aim of the current study was to examine whether neural reserve influenced the duration of post-traumatic amnesia (PTA) following mild traumatic brain injury (MTBI).

METHOD

The relationship between duration of PTA and both IQ and education was examined in a group of 59 MTBI patients. In addition, the effects of factors that could potentially diminish neural reserve, namely pre-injury hazardous alcohol consumption, pre-injury marijuana use, previous neurological damage, age and post-injury emotional distress on PTA duration were analysed.

RESULTS

Significant, negative associations between PTA duration and both IQ and education were revealed. None of the other variables that were examined were significantly related to PTA duration.

CONCLUSION

The findings were interpreted as providing preliminary evidence to suggest that reference to neural reserve may help explain between-subject variability in acute response to MTBI.

The relationship of psychological and cognitive factors and opioids in the development of the postconcussion syndrome in general trauma patients with mild traumatic brain injury

The relationship of psychological and cognitive factors in the development of the postconcussion syndrome (PCS) following mild uncomplicated traumatic brain injury (mTBI) has received little study. This may be because of the widely held belief that neurological factors are the cause of early PCS symptoms, whereas psychological factors are responsible for enduring symptoms. To further understand these relationships, the association between PCS and neuropsychological and psychological outcome was investigated in 122 general trauma patients, many of whom had orthopedic injuries, around 5 days following mTBI. Apart from verbal fluency, participants with a PCS did not differ in their performances on neuropsychological measures compared to those without a PCS. Individuals with a PCS reported significantly more psychological symptoms. Large effect sizes present on the psychological measures showed that the difference between participants with a PCS and without was greater on psychological than on neuropsychological measures. Analyses also revealed a relationship between opioid analgesia and depression, anxiety and stress, and opioids and reduced learning. The results suggest that psychological factors are present much earlier than has previously been considered in the development of the PCS.

The Rivermead Post Concussion Symptoms Questionnaire: a confirmatory factor analysis

OBJECTIVE

To investigate the factor structure of the Rivermead Post Concussion Symptoms Questionnaire (RPQ) among individuals seen as part of routine follow-up following traumatic brain injury.

METHODS

RPQ data from 168 participants was examined (mean age 35.2, SD 14.3; 89% with post traumatic amnesia duration<24 hours) six months after admission to an Accident & Emergency Department following TBI. Structural equation modelling was carried out to evaluate proposed models of the underlying structure of post-concussion symptoms (PCS).

RESULTS

The results support the existence of separate cognitive, emotional and somatic factors, although there was a high degree of covariation between the three factors. A two-factor model that collapsed the emotional and somatic factors together showed a similar goodness-of-fit to the data, whilst a one-factor model proved a poor fit.

CONCLUSION

The results support the notion of post-concussion symptoms as a collection of associated but at least partially separable cognitive, emotional and somatic symptoms, although questions persist regarding symptom specificity. The use of the RPQ is discussed, and classification bands for use in clinical practice are suggested.

Randomized treatment trial in mild traumatic brain injury

OBJECTIVE

To determine whether multidisciplinary treatment of mild traumatic brain injury (MTBI) improves neurobehavioral outcome at 6 months postinjury.

METHODS

Subjects with MTBI were randomly assigned to treatment (n=97) or nontreatment (control, n=94) groups. Treated patients were assessed within 1 week of injury and thereafter managed by a multidisciplinary team according to clinical need for a further 6 months. Control subjects were not offered treatment. Six-month outcome measures included: severity of postconcussive symptoms (Rivermead Post-Concussion Disorder Questionnaire), psychosocial functioning (Rivermead Follow-up Questionnaire), psychological distress (General Health Questionnaire), and cognition (neurocognitive battery).

RESULTS

Treatment and control subjects were well-matched for demographic and MTBI severity data. In addition, the two groups did not differ on any outcome measure. However, in individuals with preinjury psychiatric difficulties (22.9% of the entire sample), subjects in the treatment group had significantly fewer depressive symptoms 6 months postinjury compared with untreated controls (P=.01).

CONCLUSIONS

These findings suggest that routine treatment of all MTBI patients offers little benefit; rather, targeting individuals with preinjury psychiatric problems may prove a more rational and cost-effective approach.

Emergency department management of mild traumatic brain injury in the USA

OBJECTIVE

To describe the emergency department (ED) management of isolated mild traumatic brain injury (TBI) in the USA and to examine variation in care across age and insurance types.

METHODS

A secondary analysis of ED visits for isolated mild TBI in the National Hospital Ambulatory Medical Care Survey 1998-2000 was performed. Mild TBI was defined by International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9) codes for skull fracture, concussion, intracranial injury (unspecified), and head injury (unspecified). Available ED care variables were analysed by patient age and insurance categories using multivariate logistic regression.

RESULTS

The incidence of isolated mild TBI cases attending ED was 153,296 per year, or 56.4/100,000 people. Of the patients with isolated mild TBI, 44.3% underwent computed tomography, 23.9% underwent other non-extremity, non-chest x rays, 17.1% received wound care and 14.1% received intravenous fluids. However, only 43.8% had an assessment of pain. Of those with documented pain, only 45.5% received analgesics in the ED. Nearly 38% were discharged without recommendations for specific follow up. Several aspects of ED care varied by age but not by insurance type.

CONCLUSION

Substantial ED resources are devoted to the care of isolated mild TBI. The present study identified deficiencies in and variation around several important aspects of ED care. The development of guidelines specific for mild TBI could reduce variation and improve emergency care for this injury.

Physical complaints, medical service use, and social and employment changes following mild traumatic brain injury: a 6-month longitudinal study

Using a prospective, dual-cohort study design in which selected preinjury factors were controlled, we present outcomes of 235 patients in a case cohort and 235 patients in a comparison cohort following emergency-department-diagnosed mild traumatic brain injury (MTBI). Symptoms, medical services use, and social and employment concerns were evaluated 6 months after the injury. After adjusting for preinjury characteristics, headaches, dizziness, vision difficulties, memory or learning problems, and alcohol intolerance were found to occur significantly more often in the MTBI cohort than in the comparison cohort. Problems sleeping, use of prescribed medications, and changes in employment were less likely in the MTBI cohort. Although MTBI is not life threatening, our findings suggest that 6 months after injury persons still have related health problems that require routine medical management.

A comparison of a preparticipation evaluation history form and a symptom-based concussion survey in the identification of previous head injury in collegiate athletes

OBJECTIVE

The purpose of this study was to compare the incidence of prior head injury reported on preparticipation physical evaluation (PPE) history forms with a retrospective symptom-based survey.

DESIGN

A comparison of 2 retrospective survey instruments.

SETTING

NCAA Division I varsity athletic program.

PARTICIPANTS

A total of 93 male and 79 female athletes participating in intercollegiate contact/collision sports.

MAIN OUTCOME MEASURES

Athletes were administered a concussion symptom survey (CSS) with questions about symptom incidence after head injury. These responses were compared with answers given about previous concussion/head injury on the university's PPE history form. The numbers of positive responses were analyzed using descriptive statistics, and differences between the PPE medical history form and the concussion symptom survey were assessed using chi analysis. Factor analysis was performed to assess for possible variance structure between reported symptoms.

RESULTS

Seventy-one percent of athletes reporting symptoms consistent with concussion were not identified as having a history of head injury on the PPE medical history form. The most common symptom on the CSS was headache, which accounted for 46 (56.1%) positive responses.

CONCLUSIONS

The CSS revealed greater numbers of athletes experiencing symptomatic head injuries than the screening questions on the PPE history form. Screening for signs and symptoms of concussion may enhance the sensitivity of the PPE in detecting a prior history of concussion.

S-100B Concentration Is Not Related to Neurocognitive Performance in the First Month after Mild Traumatic Brain Injury

The serum concentration of S-100B is reported to reflect the severity of brain damage. The purpose of this study was to determine whether elevated serum S-100B concentrations were related to neuropsychological test performance of patients in the subacute phase of recovery from mild traumatic brain injury (TBI). S-100B concentrations were measured in blood samples taken within 6 h after TBI. Serum S-100B was estimated using an immunoluminometric assay. Cognitive speed and memory were assessed with neuropsychological tests at a median of 13 days (range 7-21 days) after injury. The two groups, formed on a median split of initial serum S-100B concentrations (>or<0.22 microg/l) did not differ in age or education. The neuropsychological performance of the TBI patients was also compared with that of a healthy control group. Cognitive speed and memory performance of mild TBI patients were inferior compared to those of healthy subjects. There were no significant differences within the TBI group when serum S-100B concentration was taken into consideration. The findings suggest that serum S-100B levels after mild TBI are not predictive of neuropsychological performance in the subacute stage of recovery.

Post concussion syndrome

Individuals sustaining mild traumatic brain injuries often report a constellation of physical, cognitive, and emotional/behavioral symptoms referred to as post concussion symptoms (PCS). The most commonly reported post concussion symptoms are headache, dizziness, decreased concentration, memory problems, irritability, fatigue, visual disturbances, sensitivity to noise, judgment problems, depression, and anxiety. Although these PCS often resolve within one month, in some individuals PCS can persist from months to years following injury and may even be permanent and cause disability. When this cluster of PCS is persistent in nature, it is often called the post concussion syndrome or persistent PCS. Both physiological and psychological etiologies have been suggested as causes for persistent post concussion symptoms and this has led to much controversy and debate in the literature. Most investigators now believe that a variety of pre-morbid, injury-related, and post-morbid neuropathological and psychological factors contribute to the development and continuation of these symptoms in those sustaining mild traumatic brain injury (MTBI).

Changes in event-related potentials in a three-stimulus auditory oddball task after mild head injury

Previous research has demonstrated changes in event-related potentials in a variety of cognitive tasks after severe closed head injury. We sought to establish if similar changes were present in patients who had sustained only apparently mild head injury (MHI) by recording event-related potentials in a group of 24 mild head injured and 24 control participants during a three-stimulus auditory target detection task. For this "oddball" task participants were required to press a button every time they heard a rare target tone and to ignore rare novel sounds and frequent non-target tones. Neuropsychological test results indicated that the mild head injured group had mild memory and attention impairments. Analysis of behavioural performance on the three-stimulus "oddball" task showed no difference in reaction times or error rates between the two groups. Target condition N2 deflections appeared to be larger in the mild head injured but peak amplitude measures revealed that this effect was not significant. There were no significant differences in the amplitude or latency of the P3b evoked by target stimuli or the P3a evoked by novel stimuli. However, a putative "O-wave" or "reorienting negativity" following the P3a was more negative in the mild head injured group suggesting increased activation of components of the attention network. These findings lend support to the hypothesis that MHI can cause subtle cognitive impairments that are associated with abnormal allocation of attention resources in the context of normal behavioural performance.

The effects of litigation on symptom expression: a prospective study following mild traumatic brain injury

OBJECTIVE

To prospectively assess the association between litigation and neurobehavioural symptoms following mild Traumatic Brain Injury (TBI).

DESIGN

a prospective study with the inception cohort assessed on average 42.2(17.2) days after injury.

SETTING

an outpatient clinic within a large general hospital.

PATIENTS

a consecutive sample of 100 clinic attenders with mild TBI.

OUTCOME MEASURES

A cognitive screen (Mini-Mental State Examination (MMSE), Galveston Orientation and Amnesia Test (GOAT), a measure of psychological distress (the 28 item General Health Questionnaire (GHQ)) and two head injury outcome measures, the Glasgow Outcome Scale (GOS) and the Rivermead Head Injury Follow-up Questionnaire (RHFUQ).

RESULTS

Demographic characteristics, TBI severity ratings and premorbid risk factors for poor outcome did not differ between litigants (27.8 per cent of the sample) and non-litigants. However, litigants were significantly more anxious (p<0.0001), depressed (p<0.01), had greater social dysfunction (p<0.0001) and had poorer outcome on the GOS (p<0.002) and RHFUQ (p<0.002). There were no cognitive differences between the groups.

CONCLUSIONS

the data demonstrate an association between litigation and increased psychological distress at the outset of the litigation process. While association is not synonymous with causality, the absence of demographic, premorbid and TBI related differences between litigants and non-litigants suggests that the pursuit of compensation may influence the subjective expression of symptoms following mild traumatic brain injury.

The clinical value of serum S-100 protein measurements in minor head injury: a Scandinavian multicentre study

PURPOSE

This study of patients with minor head injury was designed to investigate the relation of S-100 protein measurements to computed tomograpy (CT) findings and patients outcomes. Increased serum levels of this protein were hypothetized to predict intracranial pathology and increased frequency of post-concussion symptoms.

METHODS

One hundred and eighty-two patients were studied with Glasgow Coma Scale scores of 13-15. The study recruited patients from three Scandinavian neurotrauma centres. Serum levels of S-100 protein were measured at admittance and CT scans of the brain were obtained within 24 hours postinjury in all patients. Outcome was evaluated with the Rivermead Postconcussion Symptoms Questionnaire (RPQ) 3 months after the injury.

RESULTS

Increased serum level of S-100 protein was detected in 69 (38%) patients, and CT scan demonstrated intracranial pathology in 10 (5%) (brain contusion in seven, epidural haematoma in two, traumatic subarachnoid haemorrhage in one). The proportion of patients with detectable serum level was significantly (p < 0.01) higher among those with intracranial pathology (90%) compared to those without (35%). The negative predictive value of an undetectable S-100 level was 0.99. Sixty-two per cent reported one or more post-concussion symptoms at follow-up. A trend was observed towards an increased frequency of post-concussion symptoms among patients with detectable serum levels.

CONCLUSIONS

Undetectable serum level of S-100 protein predicts normal intracranial findings on CT scan. Determination of S-100 protein in serum may be used to select patients for CT scanning. Increased S-100 serum levels may be more related to post-concussion symptoms caused by mild traumatic brain injury than to symptoms of psychological origin.

Traumatic brain damage in minor head injury: relation of serum S-100 protein measurements to magnetic resonance imaging and neurobehavioral outcome

OBJECTIVE

The present study was conducted to validate S-100 protein as a marker of brain damage after minor head injury.

METHODS

We studied 50 patients with minor head injuries and Glasgow Coma Scale scores of 13 to 15 in whom computed tomographic scans of the brain revealed no abnormalities. Serum levels of S-100 protein were measured at admittance and hourly thereafter until 12 hours after injury. Magnetic resonance imaging and baseline neuropsychological examinations were performed within 48 hours, and neuropsychological follow-up was conducted at 3 months postinjury.

RESULTS

Fourteen patients (28%) had detectable serum levels of S-100 protein (mean peak value, 0.4 microg/L [standard deviation, +/- 0.3]). The S-100 protein levels were highest immediately after the trauma, and they declined each hour thereafter. At 6 hours postinjury, the serum level was below the detection limit (0.2 microg/L) in five (36%) of the patients with initially detectable levels. Magnetic resonance imaging revealed brain contusions in five patients, four of whom demonstrated detectable levels of S-100 protein in serum. The proportion of patients with detectable serum levels was significantly higher when magnetic resonance imaging revealed a brain contusion. In patients with detectable serum levels, we observed a trend toward impaired neuropsychological functioning on measures of attention, memory, and information processing speed.

CONCLUSION

Determination of S-100 protein levels in serum provides a valid measure of the presence and severity of traumatic brain damage if performed within the first hours after minor head injury.

Assessment of Mild Head Injury with ERPs and Neuropsychological Tasks

Abstract Mild head injury can result in the development of persistent symptoms including impairments of memory and attention in a small but significant minority. The problem in assessing these difficulties in such cases is the likely interaction of psychogenic and organic causes. The aim of the present research is to more accurately characterize the nature of these cognitive deficits. Twelve asymptomatic volunteers, who had experienced a mild head injury in the last 3.5 years, were compared to a matched control group. ERPs were recorded during the performance of the paced auditory serial addition task (PASAT) and a 3-stimulus auditory “oddball” task. Verbal paired associate. Trails A and B, Digit Symbol, Rey Figure Recall, NART, and Digit Span were also administered. The mild head injured group showed evidence of a mild impairment of episodic memory, slowing of attention shifting, but no changes in reaction time or error rates in either the “oddball” task or the PASAT. Although there was no evidence of impairment of brain orienting responses in the 3-stimulus auditory oddball task, there was evidence of reduced frontal negativity associated with changes in task demand in the PASAT. This particular ERP feature appears similar to those associated with activation of selective attention mechanisms, thus suggesting that these asymptomatic individuals may be showing signs of a mild impairment of allocation of attention resources.

Medicolegal issues: headache

This article addresses headache-related topics in which medicolegal issues have occurred or in which they are likely to occur. Where possible, an actual case has been presented. Most sections of this article are divided into three parts: principle of care, case history, and discussion and recommendations. When appropriate, American Academy of Neurology guidelines have been noted.