Design of an early intervention for persistent post-concussion symptoms in adolescents and young adults: A feasibility study

Serum neurofilament light chain, inflammatory markers, and kynurenine metabolites in patients with persistent post-concussion symptoms: A cohort study

BACKGROUND

Concussion leads to persistent post-concussion symptoms (PPCS) in up to one-third of those affected. While previous research has linked the initial trauma to elevated serum levels of neurofilament light chain (NFL), inflammatory markers, and neurotoxic metabolites within the kynurenine pathway, few studies have explored their relevance in PPCS. This study aims to investigate these biomarkers in PPCS patients, elucidating their relevance in the prolonged phase of concussion.

METHODS

Serum samples from 86 PPCS individuals aged 18-30 years, 2-6 months post-trauma were analyzed, with 54 providing follow-up samples after seven months. NFL was measured using single-molecule array (Simoa) technology, 13 inflammatory markers via a Luminex immunoassay, and five kynurenine metabolites using liquid chromatography-mass spectrometry. A control group of 120 healthy anonymous blood donors was recruited for comparison.

RESULTS

No significant NFL differences were found in PPCS participants compared with healthy individuals (p = 0.22). Intriguingly, a subset (9.3%) of PPCS participants initially exhibited abnormally high NFL levels (>9.7 pg/mL), which normalized upon follow-up (p = 0.032). Additionally, serum levels of the inflammatory markers, monocyte chemoattractant protein-1 (MCP-1/CCL2), and eotaxin-1/CCL11 were 25-40% lower than in healthy individuals (p ≤ 0.001). As hypothesized, PPCS participants exhibited a 22% reduction in the ratio of kynurenic acid to quinolinic acid (neuroprotective index) (p < 0.0001), indicating a shift towards the formation of neurotoxic metabolites.

CONCLUSION

NFL may serve as a biomarker to monitor recovery, and future studies should investigate the potential therapeutic benefits of modulating the kynurenine pathway to improve PPCS.

Serum calcitonin gene-related peptide in patients with persistent post-concussion symptoms, including headache: a cohort study

BACKGROUND

Calcitonin gene-related peptide (CGRP) plays an important role in migraine pathophysiology, and post-traumatic headache (PTH) frequently presents with migraine-like features. Despite several clinical similarities, few studies have explored CGRP in PTH and concussion. This study investigates serum CGRP levels in patients with persistent post-concussion symptoms (PPCS), including PTH.

METHODS

This cohort study was based on serum samples from individuals aged 18-30 years with PPCS who participated in a previously published randomized controlled trial of a non-pharmacological intervention. The primary outcome was serum CGRP concentrations, determined at baseline before randomization and at follow-up 7 months later, using an enzyme-linked immunosorbent assay (ELISA). CGRP levels at baseline were compared with healthy anonymous blood donors in the same age group.

RESULTS

Baseline serum samples were collected from 86 participants with PPCS. The participants were most often female (78%) and migraine-like headache was the most frequent headache phenotype (74%). Serum CGRP levels were higher in participants with PPCS than in 120 healthy individuals (median: 158.5 pg/mL vs. 76.3 pg/mL, p = 0.050). A stratified analysis revealed that females with PPCS had a fivefold higher median than healthy females (166.3 pg/mL vs. 32.1 pg/mL, p = 0.0006), while no differences were observed in males (p = 0.83). At follow-up, CGRP levels decreased with a median change of  - 1.3 pg/mL (95% confidence interval:  - 17.6-0, p = 0.024).

DISCUSSION

Elevated serum levels of CGRP in patients with PPCS and a decrease over time suggest an involvement of CGRP in PTH/PPCS. If confirmed in other studies, it could pave the way for CGRP-targeted therapies, which could have clinical significance.

Coping strategies in patients with good outcome but chronic fatigue after aneurysmal subarachnoid hemorrhage

BACKGROUND

Fatigue is a highly prevalent and debilitating symptom among patients in the chronic phase of aneurysmal subarachnoid haemorrhage (aSAH) with no identified effective treatment. Cognitive therapy has been shown to have moderate effects on fatigue. Delineating the coping strategies used by patients with post-aSAH fatigue and relating them to fatigue severity and emotional symptoms could be a step towards developing a behavioural therapy for post-aSAH fatigue.

METHODS

Ninety-six good outcome patients with chronic post-aSAH fatigue answered the questionnaires Brief COPE, (a questionnaire defining 14 coping strategies and three Coping Styles), the Fatigue Severity Scale (FSS), Mental Fatigue Scale (MFS), Beck Depression Inventory (BDI-II) and Beck Anxiety Inventory (BAI). The Brief COPE scores were compared with fatigue severity and emotional symptoms of the patients.

RESULTS

The prevailing coping strategies were "Acceptance", "Emotional Support", "Active Coping" and "Planning". "Acceptance" was the sole coping strategy that was significantly inversely related to levels of fatigue. Patients with the highest scores for mental fatigue and those with clinically significant emotional symptoms applied significantly more maladaptive avoidant strategies. Females and the youngest patients applied more "Problem-Focused" strategies.

CONCLUSION

A therapeutic behavioural model aiming at furthering "Acceptance" and reducing passivity and "Avoidant" strategies may contribute to alleviate post-aSAH fatigue in good outcome patients. Given the chronic nature of post-aSAH fatigue, neurosurgeons may encourage patients to accept their new situation so that they can start a process of positive reframing instead of being trapped in a spiral of futile loss of energy and secondary increased emotional burden and frustration.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Interdisciplinary intervention (GAIN) for adults with post-concussion symptoms: a study protocol for a stepped-wedge cluster randomised trial

Background

Persistent post-concussion symptoms (PCS) are associated with prolonged disability, reduced health-related quality of life and reduced workability. At present, no strong evidence for treatments for people with persistent PCS exists. Our research group developed a novel intervention, “Get going After concussIoN (GAIN)”, that incorporates multiple evidence-based strategies including prescribed exercise, cognitive behavioural therapy, and gradual return to activity advice. In a previous randomised trial, GAIN provided in a hospital setting was effective in reducing symptoms in 15–30-year-olds with PCS 2–6 months post-injury. In the current study, we describe the protocol for a trial designed to test the effectiveness of GAIN in a larger municipality setting. Additionally, we test the intervention within a broader age group and evaluate a broader range of outcomes. The primary hypothesis is that participants allocated to enhanced usual care plus GAIN report a higher reduction in PCS 3 months post-intervention compared to participants allocated to enhanced usual care only.

Methods

The study is a stepped-wedge cluster-randomised trial with five clusters. The 8-week interdisciplinary GAIN program will be rolled out to clusters in 3-month intervals. Power calculation yield at least 180 participants to be enrolled. Primary outcome is mean change in PCS measured by the Rivermead Post-Concussion Symptoms Questionnaire from enrolment to 3 months after end of treatment. Secondary outcomes include participation in and satisfaction with everyday activities, labour market attachment and other behavioural measures. Self-reported outcomes are measured at baseline, by end of treatment and at 3, 6, and 18 months after end of treatment. Registry-based outcomes are measured up to 36 months after concussion.

Discussion

The trial will provide important information concerning the effectiveness of the GAIN intervention in a municipality setting. Furthermore, it will provide knowledge of possible barriers and facilitators that may be relevant for future implementation of GAIN in different settings.

Trial registration

The current GAIN trial is registered in ClinicalTrials.gov (study identifier: NCT04798885) on 20 October 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06572-7.

Psychoeducational Interventions and Postconcussive Recovery in Children and Adolescents: A Rapid Systematic Review

OBJECTIVE

The purpose of this rapid systematic review was to identify and synthesize results of empirical studies that have examined psychoeducational interventions provided to children and adolescents aged 5-19 recovering from a concussion and their families.

METHODS

This study followed the PRISMA guidelines adjusted for a rapid systematic review. We searched three databases (EMBASE, PsycInfo and MEDLINE) with key terms for concussion (or mild traumatic brain injury - mTBI), the intervention (psychoeducation, instructions, and reassurance) and the target population (children and adolescents aged 5 to 19). Our search strategy generated 2225 unique records and seven were included. We performed a quality appraisal on the included studies using the Mixed Methods Appraisal Tool (MMAT).

RESULTS

Results indicated that psychoeducational interventions had satisfactory feasibility results. Caregivers generally found the intervention to be useful to determine return to play (n=2) and understand consequences following a concussion (n=1). However, results from studies on post-concussive symptom improvement (n=4) and post-intervention concussion knowledge (n=2) showed variability and mixed findings. Methodological quality was low for most studies.

CONCLUSIONS

This present review shows that there are very few published studies on psychoeducational interventions offered to children, adolescents, and families for the post-concussion management. Current evidence suggests that those interventions are useful in guiding caregivers during their child's recovery. However, the impact of psychoeducational interventions on post-concussive recovery seems to be less clear.

Self-Rated Executive Function and Health-Related Quality of Life in Young Adults With Persistent Post-Concussion Symptoms: A Cross-Sectional Study

OBJECTIVE

To assess self-reported executive dysfunction in young adult patients with persistent post-concussion symptoms (PCS) 2-6 months post-injury, and the association with self-reported Health-Related Quality of Life (HRQoL).

METHOD

This cross-sectional study carried out in a hospital setting was a secondary analysis of data from a separate randomized trial testing the effect of a novel intervention, "Get going After concussIoN " (GAIN), for persistent PCS. Patients (18-30 years) were recruited from a clinical cohort of patients with a hospital diagnosis of concussion or referred by primary care physicians. Main measures were The Behaviour Rating Inventory of Executive Function-Adult Version providing two index scores, that is, the Metacognitive Index (MI) and the Behavioural Regulation Index (BRI), and the Quality of Life after Brain Injury-Overall Scale.

RESULTS

Compared with normative data, patients had elevated scores (i.e., worse functioning) on both the MI and the BRI. In linear regression analysis, the MI score, but not the BRI score, was negatively associated with self-reported HRQoL (MI: slope = -.27, 95% confidence interval, CI [-.53, -.02], p = .03; BRI: slope = -.19, 95% CI [-.49, .13], p = .24), suggesting a positive association of subjective executive dysfunction and lower HRQoL. However, the association was attenuated after adjustment for self-reported psychological distress (MI: slope = -.09, 95% CI [-.34, .17], p = .51).

CONCLUSION

Self-reported executive dysfunction is common in young adult patients with persistent PCS, but not strongly associated with decreased HRQoL after adjusting for concurrent psychological distress.

Attachment and symptom reporting in adolescents and young adults after a concussion

BACKGROUND

The incidence of hospital-treated concussion is 100-300/100,000 person years. Reporting of long-lasting post-concussion symptoms (PCS) is estimated at 5-15%. Attachment insecurity is a potential vulnerability factor for physical illness and poorer disease outcomes in general. This study aimed to explore associations between attachment insecurity and PCS in young people sustaining a concussion.

METHODS

This cross-sectional study was embedded in a cohort of 15-30-year-old patients (n = 3080) 3 months after sustaining a concussion. Data were obtained from a database and questionnaires. PCS were measured by the Rivermead Post-Concussion Symptoms Questionnaire and attachment dimensions (anxiety and avoidance) by the Experiences in Close Relationships-Relationship Structures Questionnaire. Multiple linear regression models were performed to investigate the association between the attachment dimensions and PCS with adjustment for demographic, injury-related and psychological factors and with additional testing for interaction between the attachment dimensions.

RESULTS

In the final study sample, comprising 973 patients (31.6%), we found an interaction between the attachment dimensions. Hence, the effect of attachment anxiety on PCS was statistically insignificant at low avoidance (25th percentile) but significant at high avoidance (75th percentile, β = 0.64 (95%CI: 0.02; 1.26)), whereas the effect of attachment avoidance was significant regardless of level of attachment anxiety (25th percentile, β = 1.09 (95%CI: 0.18; 2.01); 75th percentile, β = 2.71 (95%CI: 1.80; 3.61)).

CONCLUSION

Attachment insecurity, especially characterised by high avoidance in combination with high anxiety, also called fearful attachment, is associated with PCS. Considering the attachment perspective can potentially improve health care for this patient group.

Cardiorespiratory Functioning in Youth with Persistent Post-Concussion Symptoms: A Pilot Study

Dysregulation of the autonomic nervous system (ANS) may play an important role in the development and maintenance of persistent post-concussive symptoms (PPCS). Post-injury breathing dysfunction, which is influenced by the ANS, has not been well-studied in youth. This study evaluated cardiorespiratory functioning at baseline in youth patients with PPCS and examined the relationship of cardiorespiratory variables with neurobehavioral outcomes. Participants were between the ages of 13-25 in two groups: (1) Patients with PPCS (concussion within the past 2-16 months; n = 13) and (2) non-injured controls (n = 12). Capnometry was used to obtain end-tidal CO2 (EtCO2), oxygen saturation (SaO2), respiration rate (RR), and pulse rate (PR) at seated rest. PPCS participants exhibited a reduced mean value of EtCO2 in exhaled breath (M = 36.3 mmHg, SD = 2.86 mmHg) and an altered inter-correlation between EtCO2 and RR compared to controls. Neurobehavioral outcomes including depression, severity of self-reported concussion symptoms, cognitive catastrophizing, and psychomotor processing speed were correlated with cardiorespiratory variables when the groups were combined. Overall, results from this study suggest that breathing dynamics may be altered in youth with PPCS and that cardiorespiratory outcomes could be related to a dimension of neurobehavioral outcomes associated with poorer recovery from concussion.

Microstructural changes in the brain after long-term post-concussion symptoms: A randomized trial

A recent randomized controlled trial in young patients with long-term post-concussion symptoms showed that a novel behavioral intervention "Get going After concussIoN" is superior to enhanced usual care in terms of symptom reduction. It is unknown whether these interventional effects are associated with microstructural brain changes. The aim of this study was to examine whether diffusion-weighted MRI indices, which are sensitive to the interactions between cellular structures and water molecules' Brownian motion, respond differently to the interventions of the above-mentioned trial and whether such differences correlate with the improvement of post-concussion symptoms. Twenty-three patients from the intervention group (mean age 22.8, 18 females) and 19 patients from the control group (enhanced usual care) (mean age 23.9, 14 females) were enrolled. The primary outcome measure was the mean kurtosis tensor, which is sensitive to the microscopic complexity of brain tissue. The mean kurtosis tensor was significantly increased in the intervention group (p = 0.003) in the corpus callosum but not in the thalamus (p = 0.78) and the hippocampus (p = 0.34). An increase in mean kurtosis tensor in the corpus callosum tended to be associated with a reduction in symptoms, but this association did not reach significance (p = 0.059). Changes in diffusion tensor imaging metrics did not differ between intervention groups and were not associated with symptoms. The current study found different diffusion-weighted MRI responses from the microscopic cellular structures of the corpus callosum between patients receiving a novel behavioral intervention and patients receiving enhanced usual care. Correlations with improvement of post-concussion symptoms were not evident.

Long-Term Impact of Mild Traumatic Brain Injuries on Multiple Functional Outcomes and Epigenetics: A Pilot Study with College Students

People who suffer a mild traumatic brain injury (mTBI) have heterogeneous symptoms and disease trajectories, which make it difficult to precisely assess long-term complications. This pilot study assessed and compared deficits in cognitive, psychosocial, visual functions, and balance performance between college students with and without histories of mTBI. Global DNA methylation ratio (5-mC%) in blood was also compared as a peripheral epigenetic marker. Twenty-five volunteers participated, including 14 healthy controls (64.3% females; mean age of 22.0) and 11 mTBI cases (27.3% females; mean age of 28.7 years) who self-reported mTBI history (63.6% multiple; 2.5 ± 1.29 injuries) with 7.1 years on average elapsed following the last injury. Every participant was assessed for cognitive (executive function, memory, and processing speed), psychological (depression, anxiety, and sleep disturbances), and visual function (by King–Devick and binocular accommodative tests); force-plate postural balance performance; and blood 5-mC% levels. Students with mTBI showed poorer episodic memory, severe anxiety, and higher blood 5-mC% ratio, compared to controls (all p’s < 0.05), which were still significant after adjusting for age. No differences were detected in sleep problems (after adjusting for age), visual function, and postural balance. These findings identified changes in multiple functions and peripheral epigenetics long after mTBI.

Novel interdisciplinary intervention, GAIN, vs. enhanced usual care to reduce high levels of post-concussion symptoms in adolescents and young adults 2-6 months post-injury: A randomised trial

BACKGROUND

Evidence for effective interventions to prevent long-term sequelae after concussion is sparse. This study aimed to test the efficacy of Get going After concussIoN (GAIN), an interdisciplinary, individually-tailored intervention of 8 weeks duration based on gradual return to activities and principles from cognitive behavioural therapy.

METHODS

We conducted an open-label, parallel-group randomised trial in a hospital setting in Central Denmark Region. Participants were 15-30-year-old patients with high levels of post-concussion symptoms (PCS) 2-6 months post-concussion (i.e., a score ≥20 on the Rivermead Post-concussion Symptoms Questionnaire (RPQ)). They were randomly assigned (1:1) to either enhanced usual care (EUC) or GAIN+EUC. Masking of participants and therapists was not possible. The primary outcome was change in RPQ-score from baseline to 3-month FU. All analyses were done on an intention-to-treat basis using linear mixed-effects models. This trial is registered with ClinicalTrials.gov, number NCT02337101.

FINDINGS

Between March 1, 2015, and September 1, 2017, we included 112 patients. Patients allocated to GAIN+EUC (n=57) reported a significantly larger reduction of PCS than patients allocated to EUC (n=55) with a mean adjusted difference in improvement of 7·6 points (95% confidence interval (CI) 2·0-13·1, p=0·008), Cohen's d=0·5 (95% CI 0·1-0·9). Number needed to treat for prevention of one additional patient with RPQ ≥20 at 3-month FU was 3·6 (95% CI 2·2-11·3). No adverse events were observed.

INTERPRETATION

Compared with EUC, GAIN+EUC was associated with a larger reduction of post-concussion symptoms at 3-month FU.

FUNDING

Central Denmark Region and the foundation "Public Health in Central Denmark Region - a collaboration between municipalities and the region".

Outcomes of a brief coping skills group intervention for adults with severe postconcussion symptoms

Aim:

The aim of this study was to evaluate a brief psychologically informed coping skills group intervention for adults with severe prolonged symptoms following mild traumatic brain injury (mTBI).

Methodology & results:

Patients attended an education session about mTBI; 22 patients completed an additional coping skills group intervention, 16 declined/stopped the intervention early and 19 were not offered the intervention. At follow-up, patients who completed the intervention reported a similar degree of symptom improvement and disability as those who did not complete the intervention. The majority of patients who completed the intervention were satisfied with it and perceived it to be credible.

Conclusion:

The coping skills intervention was not associated with measurable clinical benefit. Recommendations for improving psychological interventions for mTBI are discussed.

The post-aSAH syndrome: a self-reported cluster of symptoms in patients with aneurysmal subarachnoid hemorrhage

OBJECTIVE

Although many patients recover to a good functional outcome after aneurysmal subarachnoid hemorrhage (aSAH), residual symptoms are very common and may have a large impact on the patient's daily life. The particular cluster of residual symptoms after aSAH has not previously been described in detail and there is no validated questionnaire that covers the typical problems reported after aSAH. Many of the symptoms are similar to post-concussion syndrome, which often is evaluated with the Rivermead Post-Concussion Symptoms Questionnaire (RPQ). In the present study, the authors therefore performed an exploratory use of the RPQ as a template to describe post-aSAH syndrome.

METHODS

The RPQ was administered to 128 patients in the chronic phase after aSAH along with a battery of quality-of-life questionnaires. The patients also underwent a medical examination besides cognitive and physical testing. Based on their RPQ scores, patients were dichotomized into a "syndrome" group or "recovery" group.

RESULTS

A post-aSAH syndrome was seen in 33% of the patients and their symptom burden on all RPQ subscales was significantly higher than that of patients who had recovered on all RPQ subscales. The symptom cluster consisted mainly of fatigue, cognitive problems, and emotional problems. Physical problems were less frequently reported. Patients with post-aSAH syndrome scored significantly worse on mobility and pain scores, as well as on quality-of-life questionnaires. They also had significantly poorer scores on neuropsychological tests of verbal learning, verbal short- and long-term memory, psychomotor speed, and executive functions. Whereas 36% of the patients in the recovery group were able to return to their premorbid occupational status, this was true for only 1 patient in the syndrome group.

CONCLUSIONS

Approximately one-third of aSAH patients develop a post-aSAH syndrome. These patients struggle with fatigue and cognitive and emotional problems. Patients with post-aSAH syndrome report more pain and reduced quality of life compared to patients without this cluster of residual symptoms and have larger cognitive deficits. In this sample, patients with post-aSAH syndrome were almost invariably excluded from return to work. The RPQ is a simple questionnaire covering the specter of residual symptoms after aSAH. Being able to acknowledge these patients' complaints as a defined syndrome using the RPQ should help patients to accept and cope, thereby alleviating possible secondary distress produced.