Efficacy of Psychoeducation and Cognitive Rehabilitation After Mild Traumatic Brain Injury for Preventing Post-concussional Syndrome in Individuals With High Risk of Poor Prognosis: A Randomized Clinical Trial

Psychological Constructs From the Fear Avoidance Model and Beyond as Predictors for Persisting Symptoms After Concussion: An Integrative Review

OBJECTIVES

To identify the range of evidence for relationships between psychological factors using the Fear Avoidance Model (FAM) as a guiding framework and relevant clinical outcomes in adult patients with persisting symptoms after concussion (PSaC), develop a comprehensive understanding of psychological factors that have been identified as predictors of clinical outcomes for PSaC, and contribute to the theoretical framework of the FAM for PSaC.

DATA SOURCES

Six databases (CINAHL, Embase, PsycINFO, PubMed, SportDiscus, and Web of Science) were searched by a librarian for empirical and theoretical publications and experimental and quasi-experimental study designs. The literature search was not limited by publication date restrictions. Gray literature, with the exception of doctoral dissertations, was excluded.

STUDY SELECTION

We included studies in the English language consisting of human participants aged ≥18 years. Articles must have included both outcomes pertaining to PSaC (≥3mo after injury) and psychological constructs.

DATA EXTRACTION

One reviewer extracted data from the resulting studies using a standardized data extraction form designed for this review. Two reviewers independently assessed risk of bias using the Quality in Prognosis Studies tool.

DATA SYNTHESIS

This review found numerous psychological constructs, some directly linked to the FAM, that have potential prognostic relationships with PSaC. However, research remains limited and some psychological factors central to FAM were only identified in a small number of studies (catastrophizing, cogniphobia, and avoidance), whereas other psychological factors were studied more extensively (anxiety and depression).

CONCLUSIONS

There is the need for additional evidence, and this integrative review provides an adaptation of the FAM for PSaC to be used as a guiding preliminary framework for future research. Future research should aim to include psychological factors proposed in this modified FAM to fully understand PSaC.

Heart Rate Variability Biofeedback for Mild Traumatic Brain Injury: A Randomized-Controlled Study

To determine whether heart rate variability biofeedback (HRV-BF) training, compared to a psychoeducation control condition can strengthen the integration of the central and autonomic nervous systems as measured by neuropsychological measures in patients with mild traumatic brain injury (mTBI). Participants were recruited from two university hospitals in Taipei, Taiwan. A total of 49 participants with mTBI were recruited for this study. Forty-one participants completed the study, 21 in the psychoeducation group and 20 in the HRV-BF group. Randomized controlled study. The Taiwanese Frontal Assessment Battery, the Semantic Association of Verbal Fluency Test, the Taiwanese version of the Word Sequence Learning Test, the Paced Auditory Serial Addition Test-Revised, and the Trail Making Test were used as performance-based neuropsychological functioning measures. The Checklist of Post-concussion Symptoms, the Taiwanese version of the Dysexecutive Questionnaire, the Beck Anxiety Inventory, the Beck Depression Inventory, and the National Taiwan University Irritability Scale were used as self-report neuropsychological functioning measures. Furthermore, heart rate variability pre- vs. post-training was used to measure autonomic nervous system functioning. Executive, information processing, verbal memory, emotional neuropsychological functioning, and heart rate variability (HRV) were improved significantly in the HRV-BF group at the posttest whereas the psychoeducation group showed no change. HRV biofeedback is a feasible technique following mild TBI that can improve neuropsychological and autonomic nervous system functioning. HRV-BF may be clinically feasible for the rehabilitation of patients with mTBI.

Five Challenges in Implementing Cognitive Remediation for Patients with Substance Use Disorders in Clinical Settings

Many patients with substance use disorders (SUDs) present cognitive deficits, which are associated with clinical outcomes. Neuropsychological remediation might help rehabilitate cognitive functions in these populations, hence improving treatment effectiveness. Nardo and colleagues (Neuropsychology Review, 32, 161-191, 2022) reviewed 32 studies applying cognitive remediation for patients with SUDs. They underlined the heterogeneity and lack of quality of studies in this research field but concluded that cognitive remediation remains a promising tool for addictive disorders. We capitalize on the insights of this review to identify the key barriers that currently hinder the practical implementation of cognitive remediation in clinical settings. We outline five issues to be addressed, namely, (1) the integration of cognitive remediation in clinical practices; (2) the selection criteria and individual factors to consider; (3) the timing to be followed; (4) the priority across trained cognitive functions; and (5) the generalization of the improvements obtained. We finally propose that cognitive remediation should not be limited to classical cognitive functions but should also be extended toward substance-related biases and social cognition, two categories of processes that are also involved in the emergence and persistence of SUDs.

Web-based psychoeducational interventions for managing cognitive impairment-a systematic review

Objective

Web-based rehabilitation, a branch of telerehabilitation, is carried out over the internet, unrestricted by time or place. Even though web-based interventions have been reported as feasible and effective in cases of mood disorders, for example, such evidence on the effectiveness of web-based cognitive rehabilitation remains unclear. This systematic review summarizes current knowledge on web-based psychoeducational programs aiming to manage cognitive deficits in patients with diseases that affect cognition.

Methods

Using the Ovid database and the Web of Science, we systematically searched the Cochrane Database of Systematic Reviews, Medline, and PsycINFO to identify eligible studies. The review protocol (CRD42021257315) was pre-registered with the PROSPERO International Prospective Register of Systematic Reviews. The search was performed 10/13/2022. Two reviewers independently screened titles, abstracts, and full-texts, and extracted data for the selected studies. Two independent reviewers assessed the methodological quality.

Results

The search retrieved 6,487 articles. Four studies with different patient groups (stroke, traumatic brain injury, brain tumor, and cancer) met the inclusion criteria of this systematic review. The studies examined systematic cognition-focused psychoeducational rehabilitation programs in which the patient worked independently. Three studies found positive effects on subjective cognitive functions, executive functions, and self-reported memory. No effects were found on objective cognitive functions. However, the studies had methodological weaknesses (non-randomized designs, small sample sizes, vaguely described interventions). Overall, adherence and patient satisfaction were good/excellent.

Conclusion

Web-based cognitive intervention programs are a new approach to rehabilitation and patient education. The evidence, although scarce, shows that web-based interventions are feasible and support subjective cognitive functioning. However, the literature to date is extremely limited and the quality of the studies is weak. More research with high-quality study designs is needed.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=257315, identifier: CRD42021257315.

Examining the interdisciplinary approach for treatment of persistent post-concussion symptoms in adults: a systematic review

BACKGROUND

The objective of this review is to examine the evidence for the interdisciplinary approach in treatment of persistent post-concussion symptoms in adults.

METHODS

This systematic literature search was undertaken according to the Preferred Reporting Items for Systematic and Meta-Analysis (PRISMA) guidelines. Five electronic databases were searched: CINAHL, Informit, ProQuest, PubMed and Scopus. After screening and quality assessment, the review included six studies published in English and peer-reviewed journals, between 2011 and 2021 to return contemporary evidence.

RESULTS

The results revealed that there was significant variation between measures used and the timing of the pre- and post-treatment assessment. The studies found an interdisciplinary approach to be beneficial, however, the challenges of inherent heterogeneity, lack of clarity for definitions and diagnosis, and mixed results were apparent. The interdisciplinary interventions applied in all identified studies were found to reduce post-concussion symptoms across the symptom subtypes: headache/migraine, vestibular, cognitive, ocular motor and anxiety/mood.

CONCLUSIONS

The results demonstrated evidence for a reduction in persistent post-concussion symptoms following interdisciplinary intervention. This evidence will inform health services, clinicians, sports administrators and researchers with regard to concussion clinic and rehabilitation team design and service delivery.

Proposal of a common terminology for the neuropsychological rehabilitation

The literature on neuropsychological intervention (NI) uses a variety of terms to refer to equivalent constructs, making it difficult to compare intervention programmes and their outcomes. The purpose of this work is to propose a unified terminological framework for describing NI programmes. The terminological framework was developed based on a previous proposal for common terminology by Johnstone and Stonnington (Rehabilitation of neuropsychological disorders: A practical guide for rehabilitation professionals. Psychology Press, 2011) and driven by Cognitive Psychology concepts. The terminological framework was organized into two sections: (a) NI, which includes types of NI, methods and approaches, instructional methods, and strategies; and (b) neurocognitive functions, which include temporal and spatial orientation, sensation, perception, visuo-constructional abilities, attention, memory, language, reasoning of several sorts (e.g., abstract reasoning, and numerical reasoning), and executive functions. Most NI tasks target a main neurocognitive function, but there are underlying neurocognitive functions that may impair performance in the former. Since it is difficult to create a task that is solely focused on one neurocognitive function, the proposed terminology should not be viewed as a taxonomy, but rather as dimensional, with the same task allowing to work different functions, in varying grades. Adopting this terminological framework will allow to define the targeted neurocognitive functions more accurately and simplify the comparison between NI programmes and their outcomes. Future research should focus on describing the main techniques/strategies for each neurocognitive function and non-cognitive interventions.

How completely are randomized controlled trials of non-pharmacological interventions following concussion reported? A systematic review

PURPOSE

To examine the reporting completeness of randomized controlled trials (RCTs) of non-pharmacological interventions following concussion.

METHODS

We searched MEDLINE, Embase, PsycInfo, CINAHL, and Web of Science up to May 2022. Two reviewers independently screened studies and assessed reporting completeness using the Template for Intervention Description and Replication (TIDieR), Consensus on Exercise Reporting Template (CERT), and international Consensus on Therapeutic Exercise aNd Training (i-CONTENT) checklists. Additional information was sought my study authors where reporting was incomplete. Risk of bias (ROB) was assessed with the Cochrane ROB-2 Tool. RCTs examining non-pharmacological interventions following concussion.

RESULTS

We included 89 RCTs (n = 53 high ROB) examining 11 different interventions for concussion: sub-symptom threshold aerobic exercise, cervicovestibular therapy, physical/cognitive rest, vision therapy, education, psychotherapy, hyperbaric oxygen therapy, transcranial magnetic stimulation, blue light therapy, osteopathic manipulation, and head/neck cooling. Median scores were: TIDieR 9/12 (75%; interquartile range (IQR) = 5; range: 5-12), CERT 17/19 (89%; IQR = 2; range: 10-19), and i-CONTENT 6/7 (86%; IQR = 1; range: 5-7). Percentage of studies completely reporting all items was TIDieR 35% (31/89), CERT 24% (5/21), and i-CONTENT 10% (2/21). Studies were more completely reported after publication of TIDieR (t87 = 2.08; p = 0.04) and CERT (t19 = 2.72; p = 0.01). Reporting completeness was not strongly associated with journal impact factor (TIDieR: rs = 0.27; p = 0.01; CERT: rs = -0.44; p = 0.06; i-CONTENT: rs = -0.17; p = 0.48) or ROB (TIDieR: rs = 0.11; p = 0.31; CERT: rs = 0.04; p = 0.86; i-CONTENT: rs = 0.12; p = 0.60).

CONCLUSION

RCTs of non-pharmacological interventions following concussion demonstrate moderate to good reporting completeness, but are often missing key components, particularly modifications, motivational strategies, and qualified supervisor. Reporting completeness improved after TIDieR and CERT publication, but publication in highly cited journals and low ROB do not guarantee reporting completeness.

LoveYourBrain Mindset: Feasibility, Acceptability, Usability, and Effectiveness of an Online Yoga, Mindfulness, and Psychoeducation Intervention for People with Traumatic Brain Injury

OBJECTIVE

Despite the benefits of yoga, mindfulness, and psychoeducation after traumatic brain injury (TBI), no online programming exists. This study investigated the feasibility, acceptability, usability, and effectiveness of the LoveYourBrain Mindset online program for people with TBI.

RESEARCH DESIGN

Pre-post, retrospective intervention.

METHODS

LoveYourBrain Mindset is a six-week online yoga, mindfulness, and psychoeducation program with weekly interactive Zoom classes and prerecorded mindfulness tools. Two interactive class types (45-minute group discussion, 75-minute group discussion and gentle yoga) are offered to enhance accessibility. People were eligible if they experienced TBI, were a caregiver, or clinician; ≥15 years old; and capable of gentle exercise and group discussion. We analyzed attendance, program ratings, mindfulness tools utilization, and pre/post-intervention differences in QOL, resilience, emotional/behavioral dysregulation, cognition, and positive affect/well-being.

RESULTS

Overall, 1539 individuals signed up for LoveYourBrain Mindset with 1093 (71.02%) participating in one/more classes. The mean program rating was 9.09 (SD=1.28). Majority (62.99%) used the mindfulness tools each week. Multiple linear regression models controlling for age, TBI severity, and gender indicated significant improvements in QOL, resilience, emotional/behavioral dysregulation, cognition, and positive affect/well-being (p<0.001).

CONCLUSION

LoveYourBrain Mindset is feasible, acceptable, usable, and may improve outcomes among people with TBI.

American Speech-Language-Hearing Association Clinical Practice Guideline: Cognitive Rehabilitation for the Management of Cognitive Dysfunction Associated With Acquired Brain Injury

BACKGROUND

Cognitive-communication impairments following acquired brain injury (ABI) can have devastating effects on a person's ability to participate in community, social, vocational, and academic preinjury roles and responsibilities. Guidelines for evidence-based practices are needed to assist speech-language pathologists (SLPs) and other rehabilitation specialists in the delivery of cognitive rehabilitation for the adult population.

PURPOSE

The American Speech-Language-Hearing Association, in conjunction with a multidisciplinary panel of subject matter experts, developed this guideline to identify best practice recommendations for the delivery of cognitive rehabilitation to adults with cognitive dysfunction associated with ABI.

METHOD

A multidisciplinary panel identified 19 critical questions to be addressed in the guideline. Literature published between 1980 and 2020 was identified based on a set of a priori inclusion/exclusion criteria, and main findings were pooled and organized into summary of findings tables. Following the principles of the Grading of Recommendations Assessment, Development and Evaluation Evidence to Decision Framework, the panel drafted recommendations, when appropriate, based on the findings, overall quality of the evidence, balance of benefits and harms, patient preferences, resource implications, and the feasibility and acceptability of cognitive rehabilitation.

RECOMMENDATIONS

This guideline includes one overarching evidence-based recommendation that addresses the management of cognitive dysfunction following ABI and 11 subsequent recommendations focusing on cognitive rehabilitation treatment approaches, methods, and manner of delivery. In addition, this guideline includes an overarching consensus-based recommendation and seven additional consensus recommendations highlighting the role of the SLP in the screening, assessment, and treatment of adults with cognitive dysfunction associated with ABI. Future research considerations are also discussed.

A Systematic Review of Treatments of Post-Concussion Symptoms

Approximately 10−20% of patients who have sustained a mild Traumatic Brain Injury (mTBI) show persistent post-concussion symptoms (PCS). This review aims to summarize the level of evidence concerning interventions for PCS. Following the PRISMA guidelines, we conducted a systematic review regarding interventions for PCS post-mTBI until August 2021 using the Medline, Cochrane, and Embase databases. Inclusion criteria were the following: (1) intervention focusing on PCS after mTBI, (2) presence of a control group, and (3) adult patients (≥18 y.o). Quality assessment was determined using the Incog recommendation level, and the risk of bias was assessed using the revised Cochrane risk-of-bias tool. We first selected 104 full-text articles. Finally, 55 studies were retained, including 35 that obtained the highest level of evidence. The risk of bias was high in 22 out of 55 studies. Cognitive training, psycho-education, cognitive behavioral therapy, and graded return to physical activity demonstrated some effectiveness on persistent PCS. However, there is limited evidence of the beneficial effect of Methylphenidate. Oculomotor rehabilitation, light therapy, and headache management using repetitive transcranial magnetic stimulation seem effective regarding somatic complaints and sleep disorders. The preventive effect of early (<3 months) interventions remains up for debate. Despite its limitations, the results of the present review should encourage clinicians to propose a tailored treatment to patients according to the type and severity of PCS and could encourage further research with larger groups.

Neuropsychiatric Treatment for Mild Traumatic Brain Injury: Nonpharmacological Approaches

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

Relationship between mild traumatic brain injury and the gut microbiome: A scoping review

There is increasing evidence for the important role of gut microbiota (GMB) in the development and progression of neurologic pathologies. Some studies have shown that modifying the microbiome profile can confer benefits to patients. Mild traumatic brain injury (mTBI) is a common occurrence in the general population. Although most patients recover, in a minority, disabling symptoms can persist for several months. We carried out a review of the literature to assess the effect of mTBI on GMB and to determine whether alleviating dysbiosis can improve clinical outcomes in mTBI patients. We performed searches in Medline/PubMed and Embase using the keywords "MTBI" AND "microbiome" OR "microbiota". Additional articles were identified by manual searches and using the Google search engine. In animal models, a clear perturbation of GMB was reported following TBI and probiotic supplementation (Lactobacillus acidophilus or Clostridium butyricum) improved neurologic function. There were no studies on changes in GMB after mTBI in humans; however, pre- or probiotic supplementation reduced the infection rate in patients with severe TBI and shortened the time spent in the intensive care unit without conferring any neurologic benefits. Thus, although the findings from animal models are promising, clinical studies are needed to determine whether therapeutic strategies that restore gut microbiome profile can improve long-term outcomes of patients with mTBI.

Nonpharmacological Treatment of Persistent Postconcussion Symptoms in Adults: A Systematic Review and Meta-analysis and Guideline Recommendation

IMPORTANCE

Persistent (>4 weeks) postconcussion symptoms (PPCS) are challenging for both patients and clinicians. There is uncertainty about the effect of commonly applied nonpharmacological treatments for the management of PPCS.

OBJECTIVE

To systematically assess and summarize evidence for outcomes related to 7 nonpharmacological interventions for PPCS in adults (aged >18 years) and provide recommendations for clinical practice.

DATA SOURCES

Systematic literature searches were performed via Embase, MEDLINE, PsycINFO, CINAHL, PEDro, OTseeker, and Cochrane Reviews (via MEDLINE and Embase) from earliest possible publication year to March 3, 2020. The literature was searched for prior systematic reviews and primary studies. To be included, studies had to be intervention studies with a control group and focus on PPCS.

STUDY SELECTION

A multidisciplinary guideline panel selected interventions based on frequency of use and need for decision support among clinicians, including early information and advice, graded physical exercise, vestibular rehabilitation, manual treatment of neck and back, oculomotor vision treatment, psychological treatment, and interdisciplinary coordinated rehabilitative treatment. To be included, studies had to be intervention studies within the areas of the predefined clinical questions, include a control group, and focus on symptoms after concussion or mild traumatic brain injury.

DATA EXTRACTION AND SYNTHESIS

Extraction was performed independently by multiple observers. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used for data abstraction and data quality assessment. Included studies were assessed using the Assessment of Multiple Systematic Reviews (AMSTAR) tool and the Cochrane Risk of Bias (randomized clinical trials) tool. Meta-analysis was performed for all interventions where possible. Random-effects models were used to calculate pooled estimates of effects. The level and certainty of evidence was rated and recommendations formulated according to the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework.

MAIN OUTCOMES AND MEASURES

All outcomes were planned before data collection began according to a specified protocol. The primary outcomes were the collective burden of PPCS and another outcome reflecting the focus of a particular intervention (eg, physical functioning after graded exercise intervention).

RESULTS

Eleven systematic reviews were identified but did not contribute any primary studies; 19 randomized clinical trials comprising 2007 participants (1064 women [53.0%]) were separately identified and included. Evidence for the 7 interventions ranged from no evidence meeting the inclusion criteria to very low and low levels of evidence. Recommendations were weak for early information and advice, graded physical exercise, vestibular rehabilitation, manual treatment of the neck and back, psychological treatment, and interdisciplinary coordinated rehabilitative treatment. No relevant evidence was identified for oculomotor vision treatment, so the panel provided a good clinical practice recommendation based on consensus.

CONCLUSIONS AND RELEVANCE

Based on very low to low certainty of evidence or based on consensus, the guideline panel found weak scientific support for commonly applied nonpharmacological interventions to treat PPCS. Results align with recommendations in international guidelines. Intensified research into all types of intervention for PPCS is needed.

EMDR Treatment for Persistent Post-Concussion Symptoms Following Mild Traumatic Brain Injury: A Case Study

The majority of people who experience mild traumatic brain injury (mTBI) have a healthy recovery, where initial somatic, cognitive, psychological, and behavioral mTBI-related symptoms resolve naturally within hours or days. Unfortunately, a significant minority of people develop persistent post-concussion symptoms, sometimes referred to as persistent post-concussion syndrome (pPCS), often causing severe long-term reduction in well-being and daily function. Psychological and neuropsychological treatments are typically limited to antidepressants, psychoeducation on mTBI and pPCS, basic neurorehabilitative cognitive compensatory strategies, traditional cognitive behavioral therapy, or no treatment at all. This paper discusses a single case study which demonstrates how eye movement desensitization and reprocessing (EMDR) therapy might provide psychological improvement in clients who sustain mTBI and develop pPCS. The case example describes a 57-year-old man who sustained a mTBI from a serious road traffic collision as a pedestrian and who developed pPCS. Treatment included nine 1.5-hour EMDR sessions across a 5-month period (the first being an assessment). Measures of psychological symptom change and client feedback were taken at pretreatment, midtreatment, posttreatment, and aftertreatment had ceased to gauge long-term status. Measures were taken at 18-month follow-up and 4-year review (which followed litigation settlement). The novel viability for the application of EMDR for this client group isdiscussed.

Prevalence of Post-Concussion-Like Symptoms in the General Injury Population and the Association with Health-Related Quality of Life, Health Care Use, and Return to Work

Little is known about post-concussion-like symptoms in the general injury population and the association of these symptoms with outcome after injury. This study aimed to assess the prevalence of post-concussion-like symptoms in a general injury population and describe the association between post-concussion syndrome (PCS) and health-related quality of life (HRQL), health care use, and return to work. In this longitudinal study of a cohort of injury patients, data were collected 6 and 12 months after their Emergency Department visit. Questionnaires included socio-demographics, health care utilization, return to work and the five-level version of the EuroQol five-dimensional descriptive system (EQ-5D-5L) to measure HRQL. The 12-month questionnaire included the Rivermead Post-Concussion Symptoms Questionnaire (RPQ). In total, 282 (22.0%) of the 1282 patients met the criteria for PCS. Apart from the high prevalence of PCS in patients with head injuries (29.4%), a considerable proportion of non-head injury patients also had PCS (20.6%) a year after injury. Patients with PCS had lower HRQL, lower return to work rates, and higher health care utilization, compared to patients without PCS. This underlines the importance of developing strategies to prevent post-concussion-like symptoms among injury patients, raising awareness among patients and physicians on the occurrence of PCS, early detection of PCS in the general injury population, and development of strategies to optimize recovery in this group of injury patients, ultimately leading to lower the individual and economic burden of injury.

Post-concussion syndrome: Still forgotten? From the disappearance of the DSM-5 to a multidisciplinary consultation

OBJECTIVES

Following the presence of both post-traumatic stress disorder (PTSD) and post-concussion syndrome (PCS) in the nosography since the publication of DSM-IV, large-scale studies investigated the links between these two entities: exposure to a mild traumatic brain injury was correlated with the presence of PTSD and vice versa, and the strongest factor associated with PCS was the presence of PTSD. But PCS entity was recently suppressed from the 5th edition of the American diagnostic and statistical classification of neuropsychiatric disorders (DSM-5, 2013). In the 11th edition of the CIM, PCS is also likely to be omitted. This elimination raises more questions if we take into consideration the emancipation of PTSD, which now includes the full category of "disorders related to trauma and stressors" to which PCS could have legitimately been added.

METHODS

We discuss current scientific literature and clinical practices with a socio-anthropological point of view.

RESULTS

Post-concussion and post-traumatic clinical entities often show similar anamnestic temporalities, with an initial acute phase where memory (amnesia following TBI; dissociative post-traumatic amnesia) and consciousness (initial loss of consciousness secondary to TBI; peri-traumatic psychic dissociation) impairments predominate, followed by a pauci-symptomatic latency phase. Finally, a symptomatic phase occurs in which similar symptoms for both entities are observed (sleep disorders, anxiety and depression, irritability, fatigue, attention disorder, tendency to avoidance). If similar therapies (pharmacological and psychological) are effective in treating the clinical consequences of head and mental trauma, this suggests that they have common etiopathogenic origins.

CONCLUSIONS

Yet, post-concussion syndrome remains a clinical-biological reality. If a diffusion tensor imaging MRI in the acute phase is likely to provide predictive elements for subsequent cognitive dysfunctions, it would appear useful to consider combining biomarkers, and linguistics markers, with the creation of a clinical-radio-bio- neuropsychological score in order to differentiate benign outcomes from neuro- and/or psycho-traumatic disorders.

Post-concussive symptom endorsement and symptom attribution following remote mild traumatic brain injury in combat-exposed Veterans: An exploratory study

The purpose of this study was to examine rates of and relationships between "post-concussive" symptom endorsement and symptom attribution in Veterans with a history of mild traumatic brain injury (mTBI). This cross-sectional, exploratory study included 48 combat-exposed Iraq/Afghanistan Veterans with remote history of mTBI. All Veterans completed clinical interviews and self-report questionnaires assessing sociodemographic factors, injury and combat-related variables, psychiatric distress, self-efficacy, and coping style. To assess symptom endorsement and symptom attribution, a modified version of the Neurobehavioral Symptom Inventory was administered. Results showed that the most commonly endorsed "post-concussive" symptoms were several non-specific symptoms, while the symptoms most frequently attributed to mTBI included forgetfulness, poor concentration, and headaches. Furthermore, although there were some overlapping correlates of both symptom endorsement and symptom attribution, unique variables were associated with each domain. Specifically, symptom endorsement was uniquely associated with measures of psychiatric distress, while symptom attribution was uniquely associated with having a history of loss of consciousness and a greater degree of combat exposure. Taken together, results suggest that endorsement of symptoms may be significantly impacted by the presence of mental health comorbidities, but that perceptions or beliefs as to why symptoms are occurring are related more to mTBI and combat-related characteristics. Findings offer potential avenues for therapeutic intervention, emphasize the importance of psychoeducation, and highlight the need to consider using alternate terminology for these symptoms that promotes recovery and minimizes misattribution of symptoms.

Prognostic factors for unfavorable outcome after mild traumatic brain injury. A review of literature

BACKGROUND

Unfavorable outcomes occur in 15-20% of patients with mild traumatic brain injury (mTBI). Early identification of patients at risk of unfavorable outcome is crucial for suitable management to be initiated, increasing the chances of full recovery. Many studies have been published on prognostic factors, but are not of a high level of evidence and certainty. A number of factors have been proposed and predictive models have been constructed that, although attractive, have not yet been externally validated.

OBJECTIVES

A review of literature (systematic search of PubMed and Google Scholar) assembled relevant available information about prognostic factors for unfavorable outcome after mTBI. We discuss the consistency of these findings, and the possibility and difficulty of using these factors in a daily practice.

RESULTS

It appears that the strongest and most consistent predictors are the number, severity and duration of symptoms present in the first few days after the trauma.