Mental Health Outcomes Across the Lifespan in Individuals With Persistent Post-Concussion Symptoms: A Scoping Review

The role of the physiotherapist in concussion

In the last decade, concussion research has exploded in multiple fields of scientific research. This has helped to clarify what causes, influences, and perpetuates human concussion, and displays the integral role physiotherapists play in concussion management. In this article we discuss the latest research relevant to the key role of physiotherapy in concussion management. A narrative review of the literature on concussion was conducted. The current review analyses how concussion has influenced physiotherapy in several categories: assessment, treatment, management, research rigour and building the profile of the profession. Scientific concussion research has largely converged in support of the role of physiotherapists utilising specific components including: (1) autonomic, (2) cervicogenic, (3) vestibulo-ocular and (4) psychological approaches to management. Latest research supports the critical role of physiotherapy in concussion care in the assessment, management, and prevention of concussion with scope for further interdisciplinary collaborations.

Clinical implications

Concussion is complex. A basic mental health, Vestibular Ocular Motor Screening (VOMS) and four key components relating to concussion management (autonomic, cervicogenic, vestibular oculomotor, and psychological approaches to management) should be included in the undergraduate and postgraduate curriculum. This will aid clinical physiotherapists to support their patients. A call to advance more intradisciplinary physiotherapy teamwork should be encouraged as valuable knowledge sharing is potentially lost within the framework of 'specialisation'. If needed, the skills of a greater interdisciplinary team are imperative to facilitate patient management and recovery from this multi-faceted injury.

A Cross-Sectional Investigation of Trait Mindfulness, Concussion Symptom Severity, and Quality of Life in Adults with Persisting Symptoms Postconcussion

Individual differences in mindfulness may impact quality of life after concussion. In a cross-sectional analysis, the moderating effect of mindfulness was tested on the association between symptom severity and quality of life in adults with persisting postconcussion symptoms (N = 85). Mindfulness and symptom severity were independently associated with quality of life; however, mindfulness did not moderate this association. "Nonreactivity" was independently associated with quality of life; however, it was not a significant moderator. Taking a nonreactive stance, or allowing experiences to come and go without effort to change them, may be relevant to quality-of-life outcomes after concussion.

Association between sports-related concussions and the risk of self-injury thoughts and behaviors: Who, and under what circumstances?

BACKGROUND

Understanding the association between sport-related concussions and the risk of suicidal and non-suicidal self-injury thoughts and behaviors (SITBs), including non-suicidal self-injury (NSSI), suicidal ideation (SI), suicidal plan (SP), and suicidal attempt (SA), is crucial for suicide prevention. We aimed to identify the circumstances in which individuals with or without a concussion are vulnerable to SITBs.

METHODS

The cross-sectional study included 85,469 students from 63 Chinese university with a mean age of 19.6 years. Firstly, propensity score matching, and inverse probability of treatment weighting (IPTW) were used to match the concussion and non-concussion group based on a range of biological, social, and psychological factors. Subsequently, multivariable logistic regression and a decision tree algorithm were employed to evaluate the interaction and cumulative impact of these risk factors and concussion on the probability of SITBs.

RESULTS

In the unmatched sample, concussion exposures were associated with all SITBs, with NSSI (OR, 1.41), SI (OR, 1.10), SP (OR, 1.23), and SA (OR, 1.28). However, the matched and weighted sample only had a significant association with NSSI and SI. The decision tree model revealed that, in the unmatched sample, among individuals without depressive symptoms or childhood emotional abuse, the risk of concussion on SITBs increased from 45.5 % to 65.2 % (χ2, 9.370; adjusted P = .002) after experiencing sexual abuse and verbal bullying. In the matched sample, the risk increased from 46.2 % to 64.6 % (χ2, 6.848; adjusted P = .009).

CONCLUSION

Our study revealed that individuals who suffered concussions exhibited a significantly higher risk of SITBs.

Relations between concussion symptoms and depression among patients with mild traumatic brain injury: A moderated mediation model

INTRODUCTION

Concussion symptoms following a traumatic accident are both common and known to adversely affect mental health and recovery in patients with traumatic brain injury. Depression, highly prevalent among patients with traumatic brain injury, is also associated with the important factors of sleep quality and resilience. However, the mediator and moderator roles of depression following concussion in patients with traumatic brain injury have been underexplored. The aims of this study were to investigate the mediating role of sleep quality in the relation between concussion symptoms and depression and to examine the moderating effect of resilience on this mediated model.

DESIGN

Cross-sectional pretest data analysis of a randomized controlled trial.

METHODS

A total of 249 adult patients with mild traumatic brain injury (Glasgow Coma Scale 13-15) at admission following brain injury were surveyed at a medical center in Taipei, Taiwan. The outcome variables were concussion symptoms (Rivermead Post-Concussion Symptom Questionnaire), sleep quality (Pittsburgh Sleep Quality Index), resilience (Resilience Scale for Adults), and depression (Beck Depression Inventory II). These data were analyzed using moderated mediation regressions with the SPSS PROCESS macro.

RESULTS

In patients with mild traumatic brain injury, there was a significant positive relation between concussion symptoms and depression, of which sleep quality was a significant mediator. Additionally, resilience had a negative moderating effect on the relations between sleep quality and depression. Patients with less resilience showed a stronger negative effect of sleep quality on depression.

CONCLUSION

Our findings suggest that ameliorating both concussion symptoms and sleep disturbance is important for reducing the risk of depression in patients with mild traumatic brain injury, especially in those patients with less resilience.

CLINICAL RELEVANCE

It is essential for clinical nurses to develop interventions for patients with mild traumatic brain injury that will improve their sleep quality, while strengthening their resilience, to alleviate depression.

Disrupted Maturation of White Matter Microstructure After Concussion Is Associated With Internalizing Behavior Scores in Female Children

BACKGROUND

Some children who experience concussions, particularly females, develop long-lasting emotional and behavioral problems. Establishing the potential contribution of preexisting behavioral problems and disrupted white matter maturation has been challenging due to a lack of preinjury data.

METHODS

From the Adolescent Brain Cognitive Development cohort, 239 (90 female) children age 12.1 ± 0.6 years who experienced a concussion after study entry at 10.0 ± 0.6 years were compared to 6438 (3245 female) children without head injuries who were age 9.9 ± 0.6 years at baseline and 12.0 ± 0.6 years at follow-up. The Child Behavior Checklist was used to assess internalizing and externalizing behavior at study entry and follow-up. In the children with magnetic resonance imaging data available (concussion n = 134, comparison n = 3520), deep and superficial white matter was characterized by neurite density from restriction spectrum image modeling of diffusion magnetic resonance imaging. Longitudinal ComBat harmonization removed scanner effects. Linear regressions modeled 1) behavior problems at follow-up controlling for baseline behavior, 2) impact of concussion on white matter maturation, and 3) contribution of deviations in white matter maturation to postconcussion behavior problems.

RESULTS

Only female children with concussion had higher internalizing behavior problem scores. The youngest children with concussion showed less change in superficial white matter neurite density over 2 years than children with no concussion. In females with concussion, less change in superficial white matter neurite density was correlated with increased internalizing behavior problem scores.

CONCLUSIONS

Concussions in female children are associated with emotional problems beyond preinjury levels. Injury to superficial white matter may contribute to persistent internalizing behavior problems in females.

Acceptability, usability, and credibility of a mindfulness-based digital therapeutic for pediatric concussion: A mixed-method study

Background

The ability to cope with concussion symptoms and manage stress is an important determinant of risk for prolonged symptoms.

Objective

This open-label mixed-methods pilot study assessed the acceptability and credibility of a mindfulness-based intervention delivered through a digital therapeutic (DTx; therapeutic smartphone app) for pediatric concussion.

Methods

Participants aged 12 to 18 years were recruited from an emergency department within 48 hours of a concussion (acute cohort) or from a tertiary care clinic at least 1-month post-concussion (persisting symptoms cohort). Participants completed a novel 4-week mindfulness-based intervention, for 10 to 15 minutes/day, at a minimum of 4 days/week. At 2 weeks, participants completed a credibility and expectancy questionnaire. At 4 weeks, participants completed questionnaires assessing satisfaction, usability and working alliance, as well as a semi-structured phone interview.

Results

Ten participants completed the study outcomes (7 acute; 3 persisting symptoms). The intervention was perceived as credible (median/max possible = 6.50/9.00 [6.83,8.75]) and DTx was usable (median/max possible = 70.00/100.00 [55.00,82.50]). Participants rated their satisfaction with the DTx (median/max possible = 27.00/32.00 [24.50,29.50]) and the working alliance with the digital mindfulness guides (median/max possible = 3.92/5.00 [3.38-4.33]) as high. Four themes were identified from the qualitative data: (a) positive attributes; (b) negative attributes; (c) ideas for modifications; and (d) technical issues.

Conclusion

Results show modifications to the DTx, instructions and mindfulness intervention, and potential ways to increase adherence by leveraging positive attributes. A randomized control trial will assess the effectiveness of the DTx MBI to decrease the risk of persisting symptoms and reduce the symptom burden following pediatric concussion.

Understanding the Sociocognitive Determinants Underlying Intentions to Exercise for Postconcussion Symptom Relief: An Application of the Theory of Planned Behavior

CONTEXT

This study investigated individual sociocognitive factors from the theory of planned behavior and their relationship to exercise for postconcussion recovery.

DESIGN AND METHODS

Four hundred and fifty-nine Australian adults, two-thirds of whom had no concussion history (66%), completed an online survey of their beliefs and attitudes toward exercise for postconcussion recovery. Secondary questions evaluated program design features that could affect engagement (eg, session frequency).

RESULTS

Structured equation modeling found that subjective norms were the strongest significant predictor of intention to participate in exercise for postconcussion recovery. Perceived behavioral control was also a significant predictor of intention to participate but to a lesser extent. Attitude did not predict participation intention. The design features identified as key were personalization and being supervised during the program.

CONCLUSIONS

This study found that people's intention to participate in a program of exercise postconcussion recovery is shaped by individual psychological factors and identified program design features that could be adjusted for increased engagement. Program success could be maximized through strategies such as supporting individuals to have a stronger sense of control over their participation through the choice of session timing or frequency and harnessing the influence of significant others via supportive messaging from key professionals.

Concussion Rehabilitation and the Application of Ten Movement Training Principles

Concussion awareness continues to grow in all aspects of healthcare, including the areas of prevention, acute care, and ongoing rehabilitation. Most of the concussion research to date has focussed on the challenges around screening and diagnosing what can be a complex mix of brain impairments that overlay with additional pre-existing comorbidities. While we expect further progress in concussion diagnosis, progress also continues to be made around proactive rehabilitation, with the emergence of interventions that can enhance the recovery process, maximise function and independence with a return to study, work, and play. Traditionally, optimal multimodal assessments of concussion have treated the physical, cognitive, and psychological domains of brain injury separately, which supports diagnosis, and informs appropriate follow-up care. Due to the complex nature of brain injury, multimodal assessments direct care toward professionals from many different disciplines including medicine, physiotherapy, psychology, neuropsychology, ophthalmology, and exercise physiology. In addition, these professionals may work in different fields such as sports, neurorehabilitation, vestibular, musculoskeletal, community, vocational, and general practice clinical settings. Rehabilitation interventions for concussions employed in practice are also likely to use a blend of theoretical principles from motor control, cognitive, and psychological sciences. This scale of diversity can make information dissemination, collaboration, and innovation challenging. The Ten Movement Training Principles (MTPs) have been proposed as a usable and relevant concept to guide and support clinical reasoning in neurorehabilitation. When applied to concussion rehabilitation, these same 10 principles provide a comprehensive overview of key rehabilitation strategies for current and future practice. Future collaborations can use these training principles to support clinical and research innovations including the rapid rise of technologies in this growing field of rehabilitation practice.

Emotional Regulation and Adolescent Concussion: Overview and Role of Neuroimaging

Emotional dysregulation symptoms following a concussion are associated with an increased risk for emotional dysregulation disorders (e.g., depression and anxiety), especially in adolescents. However, predicting the emergence or worsening of emotional dysregulation symptoms after concussion and the extent to which this predates the onset of subsequent psychiatric morbidity after injury remains challenging. Although advanced neuroimaging techniques, such as functional magnetic resonance imaging and diffusion magnetic resonance imaging, have been used to detect and monitor concussion-related brain abnormalities in research settings, their clinical utility remains limited. In this narrative review, we have performed a comprehensive search of the available literature regarding emotional regulation, adolescent concussion, and advanced neuroimaging techniques in electronic databases (PubMed, Scopus, and Google Scholar). We highlight clinical evidence showing the heightened susceptibility of adolescents to experiencing emotional dysregulation symptoms following a concussion. Furthermore, we describe and provide empirical support for widely used magnetic resonance imaging modalities (i.e., functional and diffusion imaging), which are utilized to detect abnormalities in circuits responsible for emotional regulation. Additionally, we assess how these abnormalities relate to the emotional dysregulation symptoms often reported by adolescents post-injury. Yet, it remains to be determined if a progression of concussion-related abnormalities exists, especially in brain regions that undergo significant developmental changes during adolescence. We conclude that neuroimaging techniques hold potential as clinically useful tools for predicting and, ultimately, monitoring the treatment response to emotional dysregulation in adolescents following a concussion.

What tests and measures accurately diagnose persisting post-concussive symptoms in children, adolescents and adults following sport-related concussion? A systematic review

OBJECTIVE

To determine what tests and measures accurately diagnose persisting post-concussive symptoms (PPCS) in children, adolescents and adults following sport-related concussion (SRC).

DESIGN

A systematic literature review.

DATA SOURCES

MEDLINE, Embase, PsycINFO, Cochrane Central Register of Controlled Trials, CINAHL and SPORTDiscus through March 2022.

ELIGIBILITY CRITERIA

Original, empirical, peer-reviewed findings (cohort studies, case-control studies, cross-sectional studies and case series) published in English and focused on SRC. Studies needed to compare individuals with PPCS to a comparison group or their own baseline prior to concussion, on tests or measures potentially affected by concussion or associated with PPCS.

RESULTS

Of 3298 records screened, 26 articles were included in the qualitative synthesis, including 1016 participants with concussion and 531 in comparison groups; 7 studies involved adults, 8 involved children and adolescents and 11 spanned both age groups. No studies focused on diagnostic accuracy. Studies were heterogeneous in participant characteristics, definitions of concussion and PPCS, timing of assessment and the tests and measures examined. Some studies found differences between individuals with PPCS and comparison groups or their own pre-injury assessments, but definitive conclusions were not possible because most studies had small convenience samples, cross-sectional designs and were rated high risk of bias.

CONCLUSION

The diagnosis of PPCS continues to rely on symptom report, preferably using standardised symptom rating scales. The existing research does not indicate that any other specific tool or measure has satisfactory accuracy for clinical diagnosis. Future research drawing on prospective, longitudinal cohort studies could help inform clinical practice.

Association between traumatic brain injury and mental health care utilization: evidence from the Canadian Community Health Survey

BACKGROUND

Mental health disorders are a common sequelae of traumatic brain injury (TBI) and are associated with worse health outcomes including increased mental health care utilization. The objective of this study was to determine the association between TBI and use of mental health services in a population-based sample.

METHODS

Using data from a national Canadian survey, this study evaluated the association between TBI and mental health care utilization, while adjusting for confounding variables. A log-Poisson regression model was used to estimate unadjusted and adjusted prevalence ratios (PR) and 95% confidence intervals (CI).

RESULTS

The study sample included 158,287 TBI patients and 25,339,913 non-injured individuals. Compared with those were not injured, TBI patients reported higher proportions of chronic mental health conditions (27% vs. 12%, p < 0.001) and heavy drinking (33% vs. 24%, p = 0.005). The adjusted prevalence of mental health care utilization was 60% higher in patients with TBI than those who were not injured (PR = 1.60, 95%; CI 1.05-2.43).

CONCLUSIONS

This study suggests that chronic mental health conditions and heavy drinking are more common in individuals with TBI. The prevalence of mental health care utilization is 60% higher in TBI patients compared with those who are not injured after adjusting for sociodemographic factors, mental health conditions, and heavy drinking. Future longitudinal research is required to examine the temporality and direction of the association between TBI and the use of mental health services.

Depressive Symptoms in Individuals With Persistent Postconcussion Symptoms: A Systematic Review and Meta-Analysis

IMPORTANCE

Approximately 15% to 30% of individuals with a history of concussion present with persistent postconcussion symptoms (PPCS). Individuals with PPCS are at greater risk of experiencing depressive symptoms.

OBJECTIVE

To synthesize the association between depressive symptoms and PPCS in children, adolescents, and adults via meta-analysis and to investigate potential moderators of that association.

DATA SOURCES

Systematic search of Ovid Medline, CINAHL, PsycInfo, and Embase from 1995 to January 2022 was performed. Additionally, references from included studies were hand-searched to ensure relevant articles were captured in the search.

STUDY SELECTION

Studies that involved participants who experienced PPCS and quantified depressive symptoms were included. The definition of PPCS was limited to physician-diagnosed or self-reported concussion, with symptoms lasting for a minimum of 4 weeks postinjury. Two authors independently screened all articles to determine study eligibility.

DATA EXTRACTION AND SYNTHESIS

Study characteristics were extracted independently by 2 trained investigators. Study data were meta-analyzed using a random-effects meta-analysis.

EXPOSURE

PPCS.

MAIN OUTCOMES AND MEASURES

The the primary outcome was depressive symptoms.

RESULTS

Data were extracted from 18 studies with a total of 9101 participants. Of the 18 studies, all were cohort studies, and 13 (72%) comprised adult populations. The mean (SD) time since concussion was 21.3 (18.7) weeks. After accounting for potential publication bias, the random-effects meta-analysis found a significant positive association between PPCS and depressive symptoms, (odds ratio, 4.56; 95% CI, 2.82-7.37; P < .001). There were no significant moderators, likely due to the small number of studies included.

CONCLUSIONS AND RELEVANCE

In this meta-analysis, experiencing PPCS was associated with a higher risk of experiencing depressive symptoms. There are several important clinical and health policy implications of the findings. Most notably, the development of strategies for effective prevention and earlier intervention to optimize mental health recovery following a concussion should be supported.