A follow-up study of patients hospitalized after minor head injury

STEP-Home transdiagnostic group reintegration workshop to improve mental health outcomes for post-9/11 Veterans: Design, methods, and rationale for a randomized controlled behavioral trial

BACKGROUND

Many post-9/11 U.S. combat Veterans experience difficulty readjusting to civilian life after military service, including relationship problems, reduced work productivity, substance misuse, and increased anger control problems. Mental health problems are frequently cited as causing these difficulties, driven by unparalleled rates of mild traumatic brain injury, posttraumatic stress, and other co-occurring emotional and physical conditions. Given the high prevalence of multimorbidity in this cohort, acceptable, non-stigmatizing, transdiagnostic interventions targeting reintegration are needed. The STEP-Home reintegration workshop has the potential to significantly improve skills to foster civilian reintegration, increase engagement in VA services, and improve mental health outcomes in Veterans with and without diagnosed clinical conditions.

METHODS/DESIGN

Ongoing from 2019, a prospective, two-site, randomized trial of 206 post-9/11 U.S. military Veterans randomized to receive either 12 sessions of the STEP-Home transdiagnostic reintegration workshop (SH; Active Intervention) or Present Centered Reintegration Group Therapy (PCRGT; Active Control Intervention). Primary outcomes are reintegration, anger, and emotional regulation post-intervention and at 3-months post-intervention. Secondary outcomes include measures of mental health, functional and vocational status, and cognition.

CONCLUSION

This study addresses an important gap in transdiagnostic interventions to improve civilian reintegration in post-9/11 Veterans. STEP-Home is designed to promote treatment engagement and retention, opening the door to critically needed VA care, and ultimately reducing long-term healthcare burden of untreated mental health illness in U.S. Veterans.

TRIAL REGISTRATION

Clinicaltrials.gov: D2907-R.

Preliminary validation of the Dutch version of the Posttraumatic stress disorder checklist for DSM-5 (PCL-5) after traumatic brain injury in a civilian population

The Posttraumatic stress disorder checklist (PCL) is the most widely used questionnaire to screen for symptoms of posttraumatic stress disorder (PTSD), based on the Diagnostic and Statistical manual of Mental disorders (DSM-IV) criteria. In the latest edition of the DSM (DSM-5), the criteria for PTSD were revised leading to the development of the PCL-5. So far, there is no validated Dutch version of the PCL-5. The aim of this study is to determine psychometric characteristics of the Dutch translation and linguistic validation of the PCL-5 and to evaluate internal consistency, criterion and structural validity. In a population of 495 civilian, traumatic brain injury patients, the PCL-5, the Generalized anxiety disorder questionnaire and the Depression scale of the Patient health questionnaire were administered. The PCL-5 was translated in Dutch following a strict procedure of linguistic validation and cognitive debriefing. Results show an excellent internal consistency and high criterion validity. Confirmatory factor analysis demonstrated a good fit for the four-factor DSM-5 model, but a superior fit for the six-factor Anhedonia model and the seven-factor Hybrid model, similar to the English version of the PCL-5. Preliminary validation of the Dutch translation of the PCL-5 was proven to be psychometrically sound and can be used for clinical and academic purposes, specifically for TBI patients. Future research should examine concurrent and discriminant validity for the Dutch translation in broader populations at risk for PTSD, and include a structured interview to evaluate diagnostic utility.

Post-Traumatic Stress Disorder after Civilian Traumatic Brain Injury: A Systematic Review and Meta-Analysis of Prevalence Rates

Post-traumatic stress disorder (PTSD) is a commonly diagnosed psychiatric disorder following traumatic brain injury (TBI). Much research on PTSD and TBI has focused on military conflict settings. Less is known about PTSD in civilian TBI. We conducted a systematic review and meta-analysis on the prevalence of PTSD after mild and moderate/severe TBI in civilian populations. We further aimed to explore the influence of methodological quality and assessment methods. A systematic literature search was performed on studies reporting on PTSD in civilian TBI, excluding studies on military populations. The risk of bias was assessed using the MORE (Methodological evaluation of Observational REsearch) checklist. Meta-analysis was conducted for overall prevalence rates for PTSD with sensitivity analyses for the severity of TBI. Fifty-two studies were included, of which 31 were graded as low risk of bias. Prevalence rates of PTSD in low risk of bias studies varied widely (2.6-36%) with a pooled prevalence rate of 15.6%. Pooled prevalence rates of PTSD for mild TBI (13.5%, 95% confidence interval [CI]: 11.7-15.3; I2 = 2%) did not differ from moderate/severe TBI (11.8, 95% CI: 7.5-16.1; I2 = 63%). Similar rates were reported in studies using different approaches and times of assessment. Although most studies that compared participants with TBI with trauma patients and healthy controls found no difference in prevalence rates of PTSD, a meta-analysis across studies revealed a higher prevalence of PTSD in patients with TBI (odds ratio [OR]: 1.73, 95% CI: 1.21-2.47). This review highlights variability between studies and emphasizes the need for higher-quality studies. Further research is warranted to determine risk factors for the development of PTSD after TBI.

Measuring Change Over Time: A Systematic Review of Evaluative Measures of Cognitive Functioning in Traumatic Brain Injury

Objectives: The purpose of evaluative instruments is to measure the magnitude of change in a construct of interest over time. The measurement properties of these instruments, as they relate to the instrument's ability to fulfill its purpose, determine the degree of certainty with which the results yielded can be viewed. This work systematically reviews all instruments that have been used to evaluate cognitive functioning in persons with traumatic brain injury (TBI), and critically assesses their evaluative measurement properties: construct validity, test-retest reliability, and responsiveness. Data Sources: MEDLINE, Central, EMBASE, Scopus, PsycINFO were searched from inception to December 2016 to identify longitudinal studies focused on cognitive evaluation of persons with TBI, from which instruments used for measuring cognitive functioning were abstracted. MEDLINE, instrument manuals, and citations of articles identified in the primary search were then screened for studies on measurement properties of instruments utilized at least twice within the longitudinal studies. Study Selection: All English-language, peer-reviewed studies of longitudinal design that measured cognition in adults with a TBI diagnosis over any period of time, identified in the primary search, were used to identify instruments. A secondary search was carried out to identify all studies that assessed the evaluative measurement properties of the instruments abstracted in the primary search. Data Extraction: Data on psychometric properties, cognitive domains covered and clinical utility were extracted for all instruments. Results: In total, 38 longitudinal studies from the primary search, utilizing 15 instruments, met inclusion and quality criteria. Following review of studies identified in the secondary search, it was determined that none of the instruments utilized had been assessed for all the relevant measurement properties in the TBI population. The most frequently assessed property was construct validity. Conclusions: There is insufficient evidence for the validity and reliability of instruments measuring cognitive functioning, longitudinally, in persons with TBI. Several instruments with well-defined construct validity in TBI samples warrant further assessment for test-retest reliability and responsiveness. Registration Number: www.crd.york.ac.uk/PROSPERO/, identifier CRD42017055309.

The course and prognostic factors of cognitive outcomes after traumatic brain injury: A systematic review and meta-analysis

Despite indications that TBI may be a precursor of cognitive decline and subsequent development of Alzheimer's disease, little is known about the time course of this relationship and the factors involved. This systematic review summarizes the evidence pertinent to this subject matter. All English language studies of longitudinal design, and works cited within them, found in six literature databases, were considered, and their quality assessed. Of 65 articles appraised, 44 studies were selected. Results were organized by timing of assessments, injury severity, and cognitive domains assessed. Differences in the course of cognitive performance were observed across injury severity groups and cognitive domains, with differential proportions of reports of improvement, decline, or no change over time. The evidence for genetic, sex-, age-, and injury-related factors as determinants of cognitive outcome was inconsistent. The non-uniform trajectory of cognitive performance post-TBI supports the notion that this construct is non-homogeneous, and that different factors influence its course. Agreement on a core set of predictors and consideration of psychometric properties of outcome measures is needed.

Magnetoencephalography Slow-Wave Detection in Patients with Mild Traumatic Brain Injury and Ongoing Symptoms Correlated with Long-Term Neuropsychological Outcome

Mild traumatic brain injury (mTBI) is common in the United States, accounting for as many as 75-80% of all TBIs. It is recognized as a significant public health concern, but there are ongoing controversies regarding the etiology of persistent symptoms post-mTBI. This constellation of nonspecific symptoms is referred to as postconcussive syndrome (PCS). The present study combined results from magnetoencephalography (MEG) and cognitive assessment to examine group differences and relationships between brain activity and cognitive performance in 31 military and civilian individuals with a history of mTBI+PCS and 33 matched healthy control subjects. An operator-free analysis was used for MEG data to increase reliability of the technique. Subjects completed a comprehensive neuropsychological assessment, and measures of abnormal slow-wave activity from MEG were collected. Results demonstrated significant group differences on measures of executive functioning and processing speed. In addition, significant correlations between slow-wave activity on MEG and patterns of cognitive functioning were found in cortical areas, consistent with cognitive impairments on exams. Results provide more objective evidence that there may be subtle changes to the neurobiological integrity of the brain that can be detected by MEG. Further, these findings suggest that these abnormalities are associated with cognitive outcomes and may account, at least in part, for long-term PCS in those who have sustained an mTBI.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Return to work following mild traumatic brain injury

OBJECTIVE

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

PARTICIPANTS

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

DESIGN

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

SETTING

Emergency Department of Tampere University Hospital, Finland.

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Virtual reality as a screening tool for sports concussion in adolescents

PRIMARY OBJECTIVE

There is controversy surrounding the cognitive effects of sports concussion. This study aimed to verify whether the technique of virtual reality could aid in the identification of attention and inhibition deficits in adolescents.

STUDY DESIGN

A prospective design was used to assess 25 sports-concussed and 25 non-sports-concussed adolescents enrolled in a sport and education programme.

METHODS AND PROCEDURES

Participants were evaluated in immersive virtual reality via ClinicaVR: Classroom-CPT and in real life via the traditional VIGIL-CPT.

MAIN OUTCOMES AND RESULTS

The neuropsychological assessment using virtual reality showed greater sensitivity to the subtle effects of sports concussion compared to the traditional test, which showed no difference between groups. The results also demonstrated that the sports concussion group reported more symptoms of cybersickness and more intense cybersickness than the control group.

CONCLUSIONS

Sports concussion was associated with subtle deficits in attention and inhibition. However, further studies are needed to support these results.

Professional Claims, Uncertainty and the Politics of Care: Impact on Referral and Equitable Care in Traumatic Brain Injury

Rising healthcare expenditure and more explicit rationing of healthcare resources is a central feature of healthcare systems globally. In Australia, reform efforts have targeted the high cost areas such as the public hospital system. This has increased the demands on professionals to reduce length of stay and complicated post-hospital referral of people with complex and severe injury. In the area of traumatic brain injury (TBI), pressures on existing rehabilitation resources and a changing healthcare environment, with greater emphasis on efficiency and evidence-based practice, confront professionals' efforts to provide equitable care. In this paper, some of the key issues important in understanding patterns of referral in TBI are presented. It is argued that referral decisions exemplify a negotiation of professional claims and value judgements that not only conceal the uncertainty in decision-making, but also more notably, reflect the lack of attention to equity in the broader politics of care. Case studies are used to illustrate these issues and to discuss the implications for equitable care in the contemporary healthcare environment in Australia. The paper concludes by outlining the challenges and opportunities in applying evidence-based decision-making in TBI and some future directions for attaining more equitable patterns of referral.

Decreased prefrontal cortex activity in mild traumatic brain injury during performance of an auditory oddball task

Up to one-third of patients with mild traumatic brain injury (TBI) demonstrate persistent cognitive deficits in the 'executive' function domain. Mild TBI patients have shown prefrontal cortex activity deficits during the performance of executive tasks requiring active information maintenance and manipulation. However, it is unclear whether these deficits are related to the executive processes themselves, or to the degree of mental effort. To determine whether prefrontal deficits also would be found during less effortful forms of executive ability, fMRI images were obtained on 31 mild TBI patients and 31 control participants during three-stimulus auditory oddball task performance. Although patients and controls had similar topographical patterns of brain activity, region-of-interest analysis revealed significantly decreased activity in right dorsolateral prefrontal cortex for mild TBI patients during target stimulus detection. Between-group analyses found evidence for potential compensatory brain activity during target detection and default-mode network dysfunction only during the detection of novel stimuli.

Traumatic alterations in consciousness: traumatic brain injury

Mild traumatic brain injury (mTBI) refers to the clinical condition of transient alteration of consciousness as a result of traumatic injury to the brain. The priority of emergency care is to identify and facilitate the treatment of rare but potentially life-threatening intracranial injuries associated with mTBI through the judicious application of appropriate imaging studies and neurosurgical consultation. Although post-mTBI symptoms quickly and completely resolve in the vast majority of cases, a significant number of patients will complain of lasting problems that may cause significant disability. Simple and early interventions such as patient education and appropriate referral can reduce the likelihood of chronic symptoms. Although definitive evidence is lacking, mTBI is likely to be related to significant long-term sequelae such as Alzheimer disease and other neurodegenerative processes.

Interview study of the effects of paediatric traumatic brain injury on memory

PRIMARY OBJECTIVE

To investigate the effects of traumatic brain injury (TBI) on children's day-to-day memory functioning.

RESEARCH DESIGN

A qualitative, interview-based procedure.

METHODS AND PROCEDURES

Thirteen parents of children and adolescents with TBI were interviewed for 2 hours. Data from 12 of the interviews were analysed using content analysis, which involved transcribing notes, sorting information into categories, identifying similarities or differences among the categories and isolating meaningful trends.

MAIN OUTCOMES AND RESULTS

Over half of the children experienced explicit (past recall) and prospective memory (future intentions) loss, but few experienced implicit memory (e.g. procedural) loss. Further, parents utilized their own interventions in minimizing their children's memory disabilities.

CONCLUSION

Memory loss is common and can impact on everyday living, but is selective in the types of memory affected. Follow-ups are recommended to assess quantitatively, the so-far, little-known effects of paediatric TBI on prospective memory and to examine more closely parent interventions to assess their wider applicability in TBI rehabilitation.

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

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

Cognitive Rehabilitation Interventions for Executive Function: Moving from Bench to Bedside in Patients with Traumatic Brain Injury

Executive function mediated by prefrontally driven distributed networks is frequently impaired by traumatic brain injury (TBI) as a result of diffuse axonal injury and focal lesions. In addition to executive cognitive functions such as planning and working memory, the effects of TBI impact social cognition and motivation processes. To encourage application of cognitive neuroscience methods to studying recovery from TBI, associated reorganization of function, and development of interventions, this article reviews the pathophysiology of TBI, critiques currently employed methods of assessing executive function, and evaluates promising interventions that reflect advances in cognitive neuroscience. Brain imaging to identify neural mechanisms mediating executive dysfunction and response to interventions following TBI is also discussed.

The neuropsychological impact of sports-related concussion: a meta-analysis

There is increasing interest in the potential neuropsychological impact of sports-related concussion. A meta-analysis of the relevant literature was conducted to determine the impact of sports-related concussion across six cognitive domains. The analysis was based on 21 studies involving 790 cases of concussion and 2014 control cases. The overall effect of concussion (d = 0.49) was comparable to the effect found in the non-sports-related mild traumatic brain injury population (d = 0.54; Belanger et al., 2005). Using sports-concussed participants with a history of prior head injury appears to inflate the effect sizes associated with the current sports-related concussion. Acute effects (within 24 hr of injury) of concussion were greatest for delayed memory, memory acquisition, and global cognitive functioning (d = 1.00, 1.03, and 1.42, respectively). However, no residual neuropsychological impairments were found when testing was completed beyond 7 days postinjury. These findings were moderated by cognitive domain and comparison group (control group versus preconcussion self-control). Specifically, delayed memory in studies utilizing a control group remained problematic at 7 days. The implications and limitations of these findings are discussed.

Factors moderating neuropsychological outcomes following mild traumatic brain injury: a meta-analysis

There continues to be debate about the long-term neuropsychological impact of mild traumatic brain injury (MTBI). A meta-analysis of the relevant literature was conducted to determine the impact of MTBI across nine cognitive domains. The analysis was based on 39 studies involving 1463 cases of MTBI and 1191 control cases. The overall effect of MTBI on neuropsychological functioning was moderate (d = .54). However, findings were moderated by cognitive domain, time since injury, patient characteristics, and sampling methods. Acute effects (less than 3 months postinjury) of MTBI were greatest for delayed memory and fluency (d = 1.03 and .89, respectively). In unselected or prospective samples, the overall analysis revealed no residual neuropsychological impairment by 3 months postinjury (d = .04). In contrast, clinic-based samples and samples including participants in litigation were associated with greater cognitive sequelae of MTBI (d = .74 and .78, respectively at 3 months or greater). Indeed, litigation was associated with stable or worsening of cognitive functioning over time. The implications and limitations of these findings are discussed.

Long-term neuropsychological outcomes following mild traumatic brain injury

Mild traumatic brain injury (MTBI) is common, yet few studies have examined neuropsychological outcomes more than 1 year postinjury. Studies of nonreferred individuals with MTBI or studies with appropriate control groups are lacking, but necessary to draw conclusions regarding natural recovery from MTBI. We examined the long-term neuropsychological outcomes of a self-reported MTBI an average of 8 years postinjury in a nonreferred community-dwelling sample of male veterans. This was a cross-sectional cohort study derived from the Vietnam Experience Study. Three groups matched on premorbid cognitive ability were examined, those who (1) had not been injured in a MVA nor had a head injury (Normal Control; n = 3214), (2) had been injured in a motor vehicle accident (MVA) but did not have a head injury (MVA Control; n = 539), and (3) had a head injury with altered consciousness (MTBI; n = 254). A MANOVA found no group differences on a standard neuropsychological test battery of 15 measures. Across 15 measures, the average neuropsychological effect size of MTBI compared with either control group was -.03. Subtle aspects of attention and working memory also were examined by comparing groups on Paced Auditory Serial Addition Test (PASAT) continuation rate and California Verbal Learning Test (CVLT) proactive interference (PI). Compared with normal controls, the MTBI group evidenced attention problems in their lower rate of continuation to completion on the PASAT (odds ratio = 1.32, CI = 1.0-1.73) and in excessive PI (odds ratio = 1.66, CI = 1.11-2.47). Unique to the MTBI group, PASAT continuation problems were associated with left-sided visual imperceptions and excessive PI was associated with impaired tandem gait. These results show that MTBI can have adverse long-term neuropsychological outcomes on subtle aspects of complex attention and working memory.

Referral to rehabilitation following traumatic brain injury: practitioners and the process of decision-making

The study aimed to examine the factors influencing referral to rehabilitation following traumatic brain injury (TBI) by using social problems theory as a conceptual model to focus on practitioners and the process of decision-making in two Australian hospitals. The research design involved semi-structured interviews with 18 practitioners and observations of 10 team meetings, and was part of a larger study on factors influencing referral to rehabilitation in the same settings. Analysis revealed that referral decisions were influenced primarily by practitioners' selection and their interpretation of clinical and non-clinical patient factors. Further, practitioners generally considered patient factors concurrently during an ongoing process of decision-making, with the combinations and interactions of these factors forming the basis for interpretations of problems and referral justifications. Key patient factors considered in referral decisions included functional and tracheostomy status, time since injury, age, family, place of residence and Indigenous status. However, rate and extent of progress, recovery potential, safety and burden of care, potential for independence and capacity to cope were five interpretative themes, which emerged as the justifications for referral decisions. The subsequent negotiation of referral based on patient factors was in turn shaped by the involvement of practitioners. While multi-disciplinary processes of decision-making were the norm, allied health professionals occupied a central role in referral to rehabilitation, and involvement of medical, nursing and allied health practitioners varied. Finally, the organizational pressures and resource constraints, combined with practitioners' assimilation of the broader efficiency agenda were central factors shaping referral.

Outcome after mild to moderate traumatic brain injury: The role of dizziness

OBJECTIVE

To assess the specific effect of dizziness on psychosocial outcome after mild to moderate traumatic brain injury (TBI).

DESIGN

Six-month cross-sectional study. Setting An outpatient TBI clinic in a tertiary care referral center. Participants A consecutive sample of 207 adults with mild to moderate TBI, 138 (66.7%) of whom had subjective complaint of posttraumatic dizziness.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Psychosocial indices (Glasgow Outcome Scale [GOS], General Health Questionnaire [GHQ], Rivermead Head Injury Follow-Up Questionnaire [RHFUQ], return to work status) were collected from dizzy and nondizzy patients.

RESULTS

Despite similar demographic, TBI, and global disability (GOS) profiles of both groups, psychosocial functioning (GHQ, RHFUQ, return to work) was significantly worse in dizzy subjects ( P <.01 for all indices). A logistic regression analysis identified dizziness ( P =.006), total GHQ ( P =.001), and psychotropic and analgesic use ( P =.05) as significant independent predictors of reemployment.

CONCLUSIONS

Although dizziness was closely linked to psychologic distress at 6 months after head injury, it also emerged as an independent predictor of failure to return to work, suggesting that not all its adverse effects on outcome are psychologically mediated. Clinicians need to be alert to the presence of dizziness as an adverse prognostic indicator after mild to moderate TBI.

Predictors of postconcussion symptom complex in community dwelling male veterans

The presence of a persistent postconcussion symptom complex (PPCSC) was examined in a non-referred sample of male veterans with a history of mild head injury and a comparison group without a history of head injury. Hierarchical logistic regression procedures were used to determine possible predictors of PPCSC using variables supported by previous research (i.e., preexisting psychiatric difficulties, demographic and social support variables, and history of an accidental injurious event). Although PPCSC was common in all groups (23% of the total sample), a significantly greater proportion of individuals in the mild head injury with loss of consciousness group (37.2%) had PPCSC compared with three other groups (head injury without loss of consciousness = 26.1%; motor vehicle accident without head injury = 23%; and control = 17.3%). However, the most salient predictors of PPCSC were early life psychiatric difficulties such as anxiety or depression, limited social support, lower intelligence, and interactions among these variables. The predictive value of loss of consciousness was significant, but low (1.4% of unique variance). The findings provide support for the premise that PPCSC is mediated in part by individual resilience, preexisting psychological status, and psychosocial support.