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King JA, Nelson LD, Cheever K, Brett B, Gliedt J, Szabo A, Dong H, Huber DL, Broglio SP, McAllister TW, McCrea M, Pasquina P, Feigenbaum LA, Hoy A, Mihalik JP, Duma SM, Buckley T, Kelly LA, Miles C, Goldman JT, Benjamin HJ, Master CL, Ortega J, Kontos A, Clugston JR, Cameron KL, Kaminski TW, Chrisman SP, Eckner JT, Port N, McGinty G. The Prevalence and Influence of New or Worsened Neck Pain After a Sport-Related Concussion in Collegiate Athletes: A Study From the CARE Consortium. Am J Sports Med 2024:3635465241247212. [PMID: 38742422 DOI: 10.1177/03635465241247212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
BACKGROUND Neck pain in a concussion population is an emerging area of study that has been shown to have a negative influence on recovery. This effect has not yet been studied in collegiate athletes. HYPOTHESIS New or worsened neck pain is common after a concussion (>30%), negatively influences recovery, and is associated with patient sex and level of contact in sport. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Varsity-level athletes from 29 National Collegiate Athletic Association member institutions as well as nonvarsity sport athletes at military service academies were eligible for enrollment. Participants completed a preseason baseline assessment and follow-up assessments at 6 and 24 to 48 hours after a concussion, when they were symptom-free, and when they returned to unrestricted play. Data collection occurred between January 2014 and September 2018. RESULTS A total of 2163 injuries were studied. New or worsened neck pain was reported with 47.0% of injuries. New or worsened neck pain was associated with patient sex (higher in female athletes), an altered mental status after the injury, the mechanism of injury, and what the athlete collided with. The presence of new/worsened neck pain was associated with delayed recovery. Those with new or worsened neck pain had 11.1 days of symptoms versus 8.8 days in those without (P < .001). They were also less likely to have a resolution of self-reported symptoms in ≤7 days (P < .001). However, the mean duration of the return-to-play protocol was not significantly different for those with new or worsened neck pain (7.5 ± 7.7 days) than those without (7.4 ± 8.3 days) (P = .592). CONCLUSION This novel study shows that neck pain was common in collegiate athletes sustaining a concussion, was influenced by many factors, and negatively affected recovery.
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Affiliation(s)
- Jeffrey A King
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Lindsay
| | - Lindsay D Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Kelly Cheever
- Applied Biomechanics Research Laboratory, Department of Kinesiology, College for Health, Community and Policy, The University of Texas at San Antonio, San Antonio, Texas, USA
| | - Benjamin Brett
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jordan Gliedt
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Aniko Szabo
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Huaying Dong
- Division of Biostatistics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel L Huber
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Steven P Broglio
- University of Michigan Concussion Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Thomas W McAllister
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Michael McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Paul Pasquina
- Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Luis A Feigenbaum
- Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - April Hoy
- Department of Athletics, School of Behavioral and Applied Sciences, Azusa Pacific University, Azusa, California, USA
| | - Jason P Mihalik
- Department of Exercise and Sport Science, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Stefan M Duma
- Institute for Critical Technology and Applied Science, Virginia Polytechnic Institute and State University, Blacksburg, Virginia, USA
| | - Thomas Buckley
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware, USA
| | - Louise A Kelly
- Department of Exercise Science, California Lutheran University, Thousand Oaks, California, USA
| | - Chris Miles
- Department of Family and Community Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Joshua T Goldman
- Departments of Family Medicine and Orthopaedic Surgery, University of California, Los Angeles, Los Angeles, California, USA
| | - Holly J Benjamin
- Departments of Orthopaedic Surgery and Rehabilitation Medicine and Pediatrics, University of Chicago, Chicago, Illinois, USA
| | - Christina L Master
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Justus Ortega
- School of Applied Health, California State Polytechnic University, Humboldt, Arcata, California, USA
| | - Anthony Kontos
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - James R Clugston
- Department of Community Health and Family Medicine, University of Florida, Gainesville, Florida, USA
| | - Kenneth L Cameron
- Orthopaedic and Sports Medicine Research, United States Military Academy, West Point, New York, USA
| | - Thomas W Kaminski
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware, USA
| | - Sara P Chrisman
- Division of Adolescent Medicine, Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - James T Eckner
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan, USA
| | - Nicholas Port
- School of Optometry, Indiana University Bloomington, Bloomington, Indiana, USA
| | - Gerald McGinty
- Department of Athletics, United States Air Force Academy, Air Force Academy, Colorado, USA
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Roberts CJ, Barber J, Temkin NR, Dong A, Robertson CS, Valadka AB, Yue JK, Markowitz AJ, Manley GT, Nelson LD. Clinical Outcomes After Traumatic Brain Injury and Exposure to Extracranial Surgery: A TRACK-TBI Study. JAMA Surg 2024; 159:248-259. [PMID: 38091011 PMCID: PMC10719833 DOI: 10.1001/jamasurg.2023.6374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 09/04/2023] [Indexed: 12/17/2023]
Abstract
Importance Traumatic brain injury (TBI) is associated with persistent functional and cognitive deficits, which may be susceptible to secondary insults. The implications of exposure to surgery and anesthesia after TBI warrant investigation, given that surgery has been associated with neurocognitive disorders. Objective To examine whether exposure to extracranial (EC) surgery and anesthesia is related to worse functional and cognitive outcomes after TBI. Design, Setting, and Participants This study was a retrospective, secondary analysis of data from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study, a prospective cohort study that assessed longitudinal outcomes of participants enrolled at 18 level I US trauma centers between February 1, 2014, and August 31, 2018. Participants were 17 years or older, presented within 24 hours of trauma, were admitted to an inpatient unit from the emergency department, had known Glasgow Coma Scale (GCS) and head computed tomography (CT) status, and did not undergo cranial surgery. This analysis was conducted between January 2, 2020, and August 8, 2023. Exposure Participants who underwent EC surgery during the index admission were compared with participants with no surgery in groups with a peripheral orthopedic injury or a TBI and were classified as having uncomplicated mild TBI (GCS score of 13-15 and negative CT results [CT- mTBI]), complicated mild TBI (GCS score of 13-15 and positive CT results [CT+ mTBI]), or moderate to severe TBI (GCS score of 3-12 [m/sTBI]). Main Outcomes and Measures The primary outcomes were functional limitations quantified by the Glasgow Outcome Scale-Extended for all injuries (GOSE-ALL) and brain injury (GOSE-TBI) and neurocognitive outcomes at 2 weeks and 6 months after injury. Results A total of 1835 participants (mean [SD] age, 42.2 [17.8] years; 1279 [70%] male; 299 Black, 1412 White, and 96 other) were analyzed, including 1349 nonsurgical participants and 486 participants undergoing EC surgery. The participants undergoing EC surgery across all TBI severities had significantly worse GOSE-ALL scores at 2 weeks and 6 months compared with their nonsurgical counterparts. At 6 months after injury, m/sTBI and CT+ mTBI participants who underwent EC surgery had significantly worse GOSE-TBI scores (B = -1.11 [95% CI, -1.53 to -0.68] in participants with m/sTBI and -0.39 [95% CI, -0.77 to -0.01] in participants with CT+ mTBI) and performed worse on the Trail Making Test Part B (B = 30.1 [95% CI, 11.9-48.2] in participants with m/sTBI and 26.3 [95% CI, 11.3-41.2] in participants with CT+ mTBI). Conclusions and Relevance This study found that exposure to EC surgery and anesthesia was associated with adverse functional outcomes and impaired executive function after TBI. This unfavorable association warrants further investigation of the potential mechanisms and clinical implications that could inform decisions regarding the timing of surgical interventions in patients after TBI.
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Affiliation(s)
- Christopher J. Roberts
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee
- Department of Anesthesiology, Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle
| | - Nancy R. Temkin
- Department of Neurological Surgery, University of Washington, Seattle
- Department of Biostatistics, University of Washington, Seattle
| | - Athena Dong
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee
- Department of Anesthesiology, Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin
| | | | - Alex B. Valadka
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas
| | - John K. Yue
- Department of Neurological Surgery, University of California, San Francisco
| | | | - Geoffrey T. Manley
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, San Francisco, California
| | - Lindsay D. Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
- Department of Neurology, Medical College of Wisconsin, Milwaukee
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DeGroot A, Huber DL, Leddy JJ, Raff H, McCrea MA, Johnson BD, Nelson LD. Use of the Buffalo Concussion Treadmill Test in community adult patients with mild traumatic brain injury. PM R 2024. [PMID: 38411367 DOI: 10.1002/pmrj.13132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 11/27/2023] [Accepted: 12/26/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND The Buffalo Concussion Treadmill Test (BCTT) is used to establish exercise tolerance for rehabilitation and identify injury subtypes for youth athletes after mild traumatic brain injury (mTBI). Its utility in adult community members is unknown. OBJECTIVE Primary: To describe how adults with and without mTBI tolerate the BCTT. Secondary: To explore relationships between baseline factors, mTBI-related symptoms, and BCTT duration. DESIGN Prospective, observational, longitudinal. SETTING Academic medical center. PARTICIPANTS Thirty-seven adults treated in a level 1 trauma center emergency department with mTBI; 24 uninjured controls (UC). INTERVENTIONS N/A. MAIN MEASURES Participants completed two visits 3 weeks apart (1 week and 1 month after mTBI) including a 15-minute BCTT, the Rivermead Post Concussion Symptoms Questionnaire (RPQ), and preinjury International Physical Activity Questionnaire. Analyses characterized BCTT response and associations between baseline factors, RPQ scores, and BCTT duration. RESULTS Persons with mTBI discontinued earlier than UC at 1-week postinjury using standard discontinuation criteria for exercise intolerance. The percentage of mTBI participants with signs of possible mTBI-related intolerance was 55.6% at 1 week (36.1% for mTBI-related symptom exacerbation, 19.4% for exertion/fatigue before reaching 85% of one's age-predicted maximum heart rate [HR]) and 48.0% at 1 month (40.0% mTBI-related symptom exacerbation, 8.0% exertion without reaching the target HR). Thirty percent of UCs completed the BCTT at both assessments. UCs met discontinuation criteria for increased nonspecific symptoms (eg, pain/general discomfort and increased Visual Analog Scale ratings; 39-61%) and physical exertion (9-26%). Shorter duration was associated with higher body mass index (r = -0.42 - -0.45), shorter height (r = 0.22-0.29), female gender (r = -0.26 - -0.27), and greater RPQ symptoms (r = -0.28 - -0.47). CONCLUSION The BCTT exacerbates mTBI-related symptoms in adult community members. Participant characteristics and noninjury factors influence performance. The findings imply the BCTT could be useful in clinical assessments of adults with mTBI. Interpretation should account for the unique characteristics of nonathletes.
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Affiliation(s)
- Andrew DeGroot
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Daniel L Huber
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - John J Leddy
- UBMD Orthopaedics and Sports Medicine; SUNY Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Hershel Raff
- Department of Medicine, Surgery, and Physiology, Medical College of Wisconsin, Milwaukee WI and the Endocrine Research Laboratory, Aurora St. Luke's Medical Center, Advocate Aurora Research Institute, Milwaukee, Wisconsin, USA
| | - Michael A McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Blair D Johnson
- Department of Kinesiology, Indiana University, Bloomington, Indiana, USA
| | - Lindsay D Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Cai LT, Brett BL, Palacios EM, Yuh EL, Bourla I, Wren-Jarvis J, Wang Y, Mac Donald C, Diaz-Arrastia R, Giacino JT, Okonkwo DO, Levin HS, Robertson CS, Temkin N, Markowitz AJ, Manley GT, Stein MB, McCrea MA, Zafonte RD, Nelson LD, Mukherjee P. Emotional Resilience Predicts Preserved White Matter Microstructure Following Mild Traumatic Brain Injury. Biol Psychiatry Cogn Neurosci Neuroimaging 2024; 9:164-175. [PMID: 36152948 PMCID: PMC10065831 DOI: 10.1016/j.bpsc.2022.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/12/2022] [Accepted: 08/31/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Adult patients with mild traumatic brain injury (mTBI) exhibit distinct phenotypes of emotional and cognitive functioning identified by latent profile analysis of clinical neuropsychological assessments. When discerned early after injury, these latent clinical profiles have been found to improve prediction of long-term outcomes from mTBI. The present study hypothesized that white matter (WM) microstructure is better preserved in an emotionally resilient mTBI phenotype compared with a neuropsychiatrically distressed mTBI phenotype. METHODS The present study used diffusion magnetic resonance imaging to investigate and compare WM microstructure in major association, projection, and commissural tracts between the two phenotypes and over time. Diffusion magnetic resonance images from 172 patients with mTBI were analyzed to compute individual diffusion tensor imaging maps at 2 weeks and 6 months after injury. RESULTS By comparing the diffusion tensor imaging parameters between the two phenotypes at global, regional, and voxel levels, emotionally resilient patients were shown to have higher axial diffusivity compared with neuropsychiatrically distressed patients early after mTBI. Longitudinal analysis revealed greater compromise of WM microstructure in neuropsychiatrically distressed patients, with greater decrease of global axial diffusivity and more widespread decrease of regional axial diffusivity during the first 6 months after injury compared with emotionally resilient patients. CONCLUSIONS These results provide neuroimaging evidence of WM microstructural differences underpinning mTBI phenotypes identified from neuropsychological assessments and show differing longitudinal trajectories of these biological effects. These findings suggest that diffusion magnetic resonance imaging can provide short- and long-term imaging biomarkers of resilience.
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Affiliation(s)
- Lanya T Cai
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - Benjamin L Brett
- Departments of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Eva M Palacios
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - Esther L Yuh
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - Ioanna Bourla
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - Jamie Wren-Jarvis
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - Yang Wang
- Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Christine Mac Donald
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Ramon Diaz-Arrastia
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts
| | - David O Okonkwo
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Harvey S Levin
- Department of Physical Medicine & Rehabilitation, Baylor College of Medicine, Houston, Texas
| | | | - Nancy Temkin
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Amy J Markowitz
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - Geoffrey T Manley
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - Murray B Stein
- Department of Psychiatry, University of California, San Diego, San Diego, California
| | - Michael A McCrea
- Departments of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ross D Zafonte
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lindsay D Nelson
- Departments of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Pratik Mukherjee
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California.
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DeGroot A, Simons MU, Huber DL, Leddy J, McCrea MA, Johnson BD, Nelson LD. Utility of Structured Oculomotor, Balance, and Exercise Testing in Civilian Adults with Mild Traumatic Brain Injury (mTBI). Am J Phys Med Rehabil 2024:00002060-990000000-00393. [PMID: 38206608 DOI: 10.1097/phm.0000000000002409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
PURPOSE Assessments of oculomotor, balance, and exercise function detect different responses to mild traumatic brain injury (mTBI) in sport-related mTBI. These assessments are understudied in the adult community mTBI population. We evaluated level 1 trauma center patients with non-sports related mTBI on oculomotor functioning (near point of convergence [NPC] and accommodation [NPA]), balance (Balance Error Scoring System [BESS]), and exercise tolerance (Buffalo Concussion Treadmill Test [BCTT]). METHODS A prospective, cohort study of adults with mTBI (N = 36) were assessed at 1 week and (N = 26) 1 month post-mTBI using NPC, NPA, BESS, BCTT, and the Rivermead Post Concussion Symptoms Questionnaire [RPQ]. Prevalence of test impairment and association between performance and mTBI-related symptom burden (RPQ scores) were characterized. RESULTS Participants demonstrated varying levels of impairment (e.g., 33.3% oculomotor, 44.1% balance, and 55.6% exercise impairment at 1 week). Participants displayed diverse impairment profiles across assessments. We observed medium-to-large correlations between poorer NPC and BCTT performance and greater mTBI symptom burden. CONCLUSIONS Clinical examinations of oculomotor function, balance, and exercise adopted from sport-related concussion assessments detect impairment in adult community members with mTBI. While findings warrant larger-scale replication, they imply that incorporating these simple, structured exams into the assessment of mTBI may facilitate more personalized management strategies.
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Affiliation(s)
- Andrew DeGroot
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee WI
| | - Mary U Simons
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee WI
| | - Daniel L Huber
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee WI
| | - John Leddy
- UBMD Orthopaedics and Sports Medicine; SUNY Buffalo Jacobs School of Medicine and Biomedical Sciences; Buffalo, NY
| | - Michael A McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee WI
| | - Blair D Johnson
- Department of Kinesiology, School of Public Health-Bloomington, Indiana University, Bloomington, IN
| | - Lindsay D Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee WI
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Eagle SR, Jain S, Sun X, Preszler J, McCrea MA, Giacino JT, Manley GT, Okonkwo DO, Nelson LD. Network analysis and relationship of symptom factors to functional outcomes and quality of life following mild traumatic brain injury: a TRACK-TBI study. Front Neurol 2023; 14:1308540. [PMID: 38148980 PMCID: PMC10750770 DOI: 10.3389/fneur.2023.1308540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 11/23/2023] [Indexed: 12/28/2023] Open
Abstract
Introduction Mild traumatic brain injury (mTBI) is a heterogenous injury which can be difficult to characterize and manage. Using cross-sectional network analysis (NA) to conceptualize mTBI symptoms offers an innovative solution to identify how mTBI symptoms relate to each other. The centrality hypothesis of network theory posits that certain symptoms in a network are more relevant (central) or have above average influence over the rest of the network. However, no studies have used NA to characterize the interrelationships between symptoms in a cohort of patients who presented with mTBI to a U.S. Level 1 trauma center emergency department and how subacute central symptoms relate to long-term outcomes. Methods Patients with mTBI (Glasgow Coma Scale = 13-15) evaluated across 18 U.S. Level 1 trauma centers from 2013 to 2019 completed the Rivermead Post-Concussion Symptoms Questionnaire (RPQ) at 2 weeks (W2) post-injury (n = 1,593) and at 3 months (M3), 6 months (M6), and 12 months (M12) post-injury. Network maps were developed from RPQ subscale scores at each timepoint. RPQ scores at W2 were associated with M6 and M12 functional and quality of life outcomes. Results Network structure did not differ across timepoints, indicating no difference in symptoms/factors influence on the overall symptom network across time. The cognitive factor had the highest expected influence at W2 (1.761), M3 (1.245), and M6 (1.349). Fatigue had the highest expected influence at M12 (1.275). The emotional factor was the only other node with expected influence >1 at any timepoint, indicating disproportionate influence of emotional symptoms on overall symptom burden (M3 = 1.011; M6 = 1.076). Discussion Several symptom factors at 2-weeks post-injury were more strongly associated with incomplete recovery and/or poorer injury-related quality of life at 6 and 12 months post-injury than previously validated demographic and clinical covariates. The network analysis suggests that emotional, cognitive, and fatigue symptoms may be useful treatment targets in this population due to high centrality and activating potential of the overall symptom network.
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Affiliation(s)
- Shawn R. Eagle
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Sonia Jain
- Department of Family Medicine and Public Health, University of California, San Diego, San Diego, CA, United States
| | - Xiaoying Sun
- Department of Family Medicine and Public Health, University of California, San Diego, San Diego, CA, United States
| | | | | | - Joseph T. Giacino
- Physical Medicine and Rehabilitation, Harvard University, Cambridge, MA, United States
| | - Geoffrey T. Manley
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, United States
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, United States
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Tritt A, Yue JK, Ferguson AR, Torres Espin A, Nelson LD, Yuh EL, Markowitz AJ, Manley GT, Bouchard KE. Data-driven distillation and precision prognosis in traumatic brain injury with interpretable machine learning. Sci Rep 2023; 13:21200. [PMID: 38040784 PMCID: PMC10692236 DOI: 10.1038/s41598-023-48054-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 11/21/2023] [Indexed: 12/03/2023] Open
Abstract
Traumatic brain injury (TBI) affects how the brain functions in the short and long term. Resulting patient outcomes across physical, cognitive, and psychological domains are complex and often difficult to predict. Major challenges to developing personalized treatment for TBI include distilling large quantities of complex data and increasing the precision with which patient outcome prediction (prognoses) can be rendered. We developed and applied interpretable machine learning methods to TBI patient data. We show that complex data describing TBI patients' intake characteristics and outcome phenotypes can be distilled to smaller sets of clinically interpretable latent factors. We demonstrate that 19 clusters of TBI outcomes can be predicted from intake data, a ~ 6× improvement in precision over clinical standards. Finally, we show that 36% of the outcome variance across patients can be predicted. These results demonstrate the importance of interpretable machine learning applied to deeply characterized patients for data-driven distillation and precision prognosis.
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Affiliation(s)
- Andrew Tritt
- Applied Math and Computational Research Division, Lawrence Berkeley National Laboratory, Berkeley, CA, USA
| | - John K Yue
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA
- Department of Neurosurgery, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Adam R Ferguson
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA
- Department of Neurosurgery, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
- San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA
| | - Abel Torres Espin
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA
- Department of Neurosurgery, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Lindsay D Nelson
- Departments of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Esther L Yuh
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA
- Department of Neurosurgery, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Amy J Markowitz
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA
- Department of Neurosurgery, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Geoffrey T Manley
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA
- Department of Neurosurgery, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
- Weill Neurohub, University of California San Francisco, San Francisco, CA, USA
- Weill Neurohub, University of California Berkeley, Berkeley, CA, USA
| | - Kristofer E Bouchard
- Weill Neurohub, University of California Berkeley, Berkeley, CA, USA.
- Scientific Data Division, Lawrence Berkeley National Laboratory, Berkeley, CA, USA.
- Biological Systems and Engineering Division, Lawrence Berkeley National Laboratory, Berkeley, CA, USA.
- Helen Wills Neuroscience Institute and Redwood Center for Theoretical Neuroscience, University of California Berkeley, Berkeley, CA, USA.
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Kontos AP, Eagle SR, Braithwaite R, Preszler J, Manderino L, Turner RL, Jennings S, Trbovich A, Hickey RW, Collins MW, McCrea M, Nelson LD, Root J, Thomas DG. The Effects of Rest on Concussion Symptom Resolution and Recovery Time: A Meta-analytic Review and Subgroup Analysis of 4329 Patients. Am J Sports Med 2023; 51:3893-3903. [PMID: 36847271 DOI: 10.1177/03635465221150214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
BACKGROUND Numerous individual studies suggest that rest may have a negative effect on outcomes following concussion. PURPOSE To perform a systematic meta-analysis of the effects of prescribed rest compared with active interventions after concussion. STUDY DESIGN Meta-analysis; Level of evidence, 4. METHODS A meta-analysis (using the Hedges g) of randomized controlled trials and cohort studies was conducted to evaluate the effects of prescribed rest on symptoms and recovery time after concussion. Subgroup analyses were performed for methodological, study, and sample characteristics. Data sources were obtained from systematic search of key terms using Ovid Medline, Embase, Cochrane Database of Systematic Reviews, APA PsycINFO, Web of Science, SPORTDiscus, and ProQuest dissertations and theses through May 28, 2021. Eligible studies were those that (1) assessed concussion or mild traumatic brain injury; (2) included symptoms or days to recovery for ≥2 time points; (3) included 2 groups with 1 group assigned to rest; and (4) were written in the English language. RESULTS In total, 19 studies involving 4239 participants met criteria. Prescribed rest had a significant negative effect on symptoms (k = 15; g = -0.27; SE = 0.11; 95% CI, -0.48 to -0.05; P = .04) but not on recovery time (k = 8; g = -0.16; SE = 0.21; 95% CI, -0.57 to 0.26; P = .03). Subgroup analyses suggested that studies with shorter duration (<28 days) (g = -0.46; k = 5), studies involving youth (g = -0.33; k = 12), and studies focused on sport-related concussion (g = -0.38; k = 8) reported higher effect sizes. CONCLUSION The findings support a small negative effect for prescribed rest on symptoms after concussion. Younger age and sport-related mechanisms of injury were associated with a greater negative effect size. However, the lack of support for an effect for recovery time and the relatively small overall numbers of eligible studies highlight ongoing concerns regarding the quantity and rigor of clinical trials in concussion. REGISTRATION CRD42021253060 (PROSPERO).
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Affiliation(s)
- Anthony P Kontos
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; UPMC Sports Medicine Concussion Program, Pittsburgh, Pennsylvania, USA
| | - Shawn R Eagle
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Rock Braithwaite
- Department of Kinesiology and Recreation Administration, Cal Poly Humboldt, Arcata, California, USA
| | - Jonathan Preszler
- UPMC Sports Medicine Concussion Program, Pittsburgh, Pennsylvania, USA
| | - Lisa Manderino
- UPMC Sports Medicine Concussion Program, Pittsburgh, Pennsylvania, USA
| | - Rose L Turner
- Health Science Library System, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Alicia Trbovich
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; UPMC Sports Medicine Concussion Program, Pittsburgh, Pennsylvania, USA
| | - Robert W Hickey
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Children's Hospital of Pittsburgh Division of Emergency Medicine, Pittsburgh, Pennsylvania, USA
| | - Michael W Collins
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; UPMC Sports Medicine Concussion Program, Pittsburgh, Pennsylvania, USA
| | - Michael McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lindsay D Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jeremy Root
- Pediatric Emergency Medicine, George Washington School of Medicine, Washington, DC, USA; Children's National Health System, Fairfax, Virginia, USA
| | - Danny G Thomas
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA; Pediatric Emergency Medicine, Children's Wisconsin, Wauwatosa, Wisconsin, USA)
- Investigation performed at University of Pittsburgh Medical Center Sports Concussion Program and University of Pittsburgh Department of Orthopaedic Surgery, Pittsburgh, Pennsylvania, USA
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Bryant AM, Rose NB, Temkin NR, Barber JK, Manley GT, McCrea MA, Nelson LD. Profiles of Cognitive Functioning at 6 Months After Traumatic Brain Injury Among Patients in Level I Trauma Centers: A TRACK-TBI Study. JAMA Netw Open 2023; 6:e2349118. [PMID: 38147333 PMCID: PMC10751593 DOI: 10.1001/jamanetworkopen.2023.49118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/09/2023] [Indexed: 12/27/2023] Open
Abstract
Importance Cognitive dysfunction is common after traumatic brain injury (TBI), with a well-established dose-response relationship between TBI severity and likelihood or magnitude of persistent cognitive impairment. However, patterns of cognitive dysfunction in the long-term (eg, 6-month) recovery period are less well known. Objective To characterize the prevalence of cognitive dysfunction within and across cognitive domains (processing speed, memory, and executive functioning) 6 months after injury in patients with TBI seen at level I trauma centers. Design, Setting, and Participants This prospective longitudinal cohort study used data from Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) and included patients aged 17 years or older presenting at 18 US level I trauma center emergency departments or inpatient units within 24 hours of head injury, control individuals with orthopedic injury recruited from the same centers, and uninjured friend and family controls. Participants were enrolled between March 2, 2014, and July 27, 2018. Data were analyzed from March 5, 2020, through October 3, 2023. Exposures Traumatic brain injury (Glasgow Coma Scale score of 3-15) or orthopedic injury. Main Outcomes and Measures Performance on standard neuropsychological tests, including premorbid cognitive ability (National Institutes of Health Toolbox Picture Vocabulary Test), verbal memory (Rey Auditory Verbal Learning Test), processing speed (Wechsler Adult Intelligence Scale [4th edition] Processing Speed Index), and executive functioning (Trail Making Test). Results The sample included 1057 persons with TBI (mean [SD] age, 39.3 [16.4] years; 705 [67%] male) and 327 controls without TBI (mean [SD] age, 38.4 [15.1] years; 222 [68%] male). Most persons with TBI demonstrated performance within 1.5 SDs or better of the control group (49.3% [95% CI, 39.5%-59.2%] to 67.5% [95% CI, 63.7%-71.2%] showed no evidence of impairment). Similarly, 64.4% (95% CI, 54.5%-73.4%) to 78.8% (95% CI, 75.4%-81.9%) of participants demonstrated no evidence of cognitive decline (defined as performance within 1.5 SDs of estimated premorbid ability). For individuals with evidence of either cognitive impairment or decline, diverse profiles of impairment across memory, speed, and executive functioning domains were observed (ie, the prevalence was >0 in each of the 7 combinations of impairment across these 3 cognitive domains for most TBI subgroups). Conclusions and Relevance In this cohort study of patients seen at level I trauma centers 6 months after TBI, many patients with TBI demonstrated no cognitive impairment. Impairment was more prevalent in persons with more severe TBI and manifested in variable ways across individuals. The findings may guide future research and treatment recommendations.
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Affiliation(s)
- Andrew M. Bryant
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
- Department of Neurology, The Ohio State University, Columbus
| | - Nathan B. Rose
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
| | - Nancy R. Temkin
- Department of Neurological Surgery, University of Washington, Seattle
- Department of Biostatistics, University of Washington, Seattle
| | - Jason K. Barber
- Department of Neurological Surgery, University of Washington, Seattle
- Department of Biostatistics, University of Washington, Seattle
| | - Geoffrey T. Manley
- Department of Neurological Surgery, University of California, San Francisco
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Eagle SR, Puccio AM, Nelson LD, McCrea M, Giacino J, Diaz-Arrastia R, Conkright W, Jain S, Sun X, Manley G, Okonkwo DO. Association of obesity with mild traumatic brain injury symptoms, inflammatory profile, quality of life and functional outcomes: a TRACK-TBI Study. J Neurol Neurosurg Psychiatry 2023; 94:1012-1017. [PMID: 37369556 DOI: 10.1136/jnnp-2023-331562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023]
Abstract
OBJECTIVES Obesity is associated with chronic inflammation, which may impact recovery from mild traumatic brain injury (mTBI). The objective was to assess the role of obesity in recovery of symptoms, functional outcome and inflammatory blood biomarkers after mTBI. METHODS TRACK-TBI is a prospective study of patients with acute mTBI (Glasgow Coma Scale=13-15) who were enrolled ≤24 hours of injury at an emergency department of level 1 trauma centres and followed for 12 months. A total of 770 hospitalised patients who were either obese (body mass index (BMI) >30.0) or healthy mass (BMI=18.5-24.9) were enrolled. Blood concentrations of high-sensitivity C reactive protein (hsCRP), interleukin (IL) 6, IL-10, tumour necrosis factor alpha; Rivermead Post-Concussion Symptoms Questionnaire (RPQ), Quality of Life After Brain Injury and Glasgow Outcome Score-Extended reflecting injury-related functional limitations at 6 and 12 months were collected. RESULTS After adjusting for age and gender, obese participants had higher concentrations of hsCRP 1 day after injury (mean difference (MD)=0.65; 95% CI: 0.44 to 0.87, p<0.001), at 2 weeks (MD=0.99; 95% CI: 0.74 to 1.25, p<0.001) and at 6 months (MD=1.08; 95% CI: 0.79 to 1.37, p<0.001) compared with healthy mass participants. Obese participants had higher concentrations of IL-6 at 2 weeks (MD=0.37; 95% CI: 0.11 to 0.64, p=0.006) and 6 months (MD=0.42; 95% CI: 0.12 to 0.72, p=0.006). Obese participants had higher RPQ total score at 6 months (MD=2.79; p=0.02) and 12 months (MD=2.37; p=0.049). CONCLUSIONS Obesity is associated with higher symptomatology at 6 and 12 months and higher concentrations of blood inflammatory markers throughout recovery following mTBI.
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Affiliation(s)
- Shawn R Eagle
- Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ava M Puccio
- Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lindsay D Nelson
- Neurosurgery & Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Michael McCrea
- Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Joseph Giacino
- Physical Medicine and Rehabilitation, Harvard University, Cambridge, Massachusetts, USA
| | | | | | - Sonia Jain
- Family Medicine and Public Health, University of California San Diego, La Jolla, California, USA
| | - Xiaoying Sun
- Family Medicine and Public Health, University of California San Diego, La Jolla, California, USA
| | - Geoffrey Manley
- Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - David O Okonkwo
- Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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11
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Wilmoth K, Brett BL, Emmert NA, Cook CM, Schaffert J, Caze T, Kotsonis T, Cusick M, Solomon G, Resch JE, Cullum CM, Nelson LD, McCrea M. Psychometric Properties of Computerized Cognitive Tools and Standard Neuropsychological Tests Used to Assess Sport Concussion: A Systematic Review. Neuropsychol Rev 2023; 33:675-692. [PMID: 36040610 DOI: 10.1007/s11065-022-09553-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 05/03/2022] [Indexed: 11/29/2022]
Abstract
Athletic programs are more frequently turning to computerized cognitive tools in order to increase efficiencies in concussion assessment. However, assessment using a traditional neuropsychological test battery may provide a more comprehensive and individualized evaluation. Our goal was to inform sport clinicians of the best practices for concussion assessment through a systematic literature review describing the psychometric properties of standard neuropsychological tests and computerized tools. We conducted our search in relevant databases including Ovid Medline, Web of Science, PsycINFO, and Scopus. Journal articles were included if they evaluated psychometric properties (e.g., reliability, sensitivity) of a cognitive assessment within pure athlete samples (up to 30 days post-injury). Searches yielded 4,758 unique results. Ultimately, 103 articles met inclusion criteria, all of which focused on adolescent or young adult participants. Test-retest reliability estimates ranged from .14 to .93 for computerized tools and .02 to .95 for standard neuropsychological tests, with strongest correlations on processing speed tasks for both modalities, although processing speed tasks were most susceptible to practice effects. Reliability was improved with a 2-factor model (processing speed and memory) and by aggregating multiple baseline exams, yet remained below acceptable limits for some studies. Sensitivity to decreased cognitive performance within 72 h of injury ranged from 45%-93% for computerized tools and 18%-80% for standard neuropsychological test batteries. The method for classifying cognitive decline (normative comparison, reliable change indices, regression-based methods) affected sensitivity estimates. Combining computerized tools and standard neuropsychological tests with the strongest psychometric performance provides the greatest value in clinical assessment. To this end, future studies should evaluate the efficacy of hybrid test batteries comprised of top-performing measures from both modalities.
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Affiliation(s)
- Kristin Wilmoth
- Departments of Psychiatry and Physical Medicine & Rehabilitation, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9055, USA.
| | - Benjamin L Brett
- Departments of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Natalie A Emmert
- Department of Neurology, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Carolyn M Cook
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jeffrey Schaffert
- Department of Psychiatry, UT Southwestern Medical Center, Dallas, TX, USA
| | - Todd Caze
- Department of Psychiatry, UT Southwestern Medical Center, Dallas, TX, USA
| | - Thomas Kotsonis
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Margaret Cusick
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Gary Solomon
- Player Health and Safety Department, National Football League and Department of Neurosurgery, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Jacob E Resch
- Department of Kinesiology, University of Virginia, Charlottesville, VA, USA
| | - C Munro Cullum
- Departments of Psychiatry, Neurology, and Neurological Surgery, UT Southwestern Medical Center, Dallas, TX, USA
| | - Lindsay D Nelson
- Departments of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Michael McCrea
- Departments of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
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12
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Wickwire EM, Albrecht JS, Capaldi VF, Jain S, Gardner RC, Smith MT, Williams SG, Collen J, Schnyer DM, Giacino JT, Nelson LD, Mukherjee P, Sun X, Werner JK, Mosti CB, Markowitz AJ, Manley GT, Krystal AD. Association Between Insomnia and Mental Health and Neurocognitive Outcomes Following Traumatic Brain Injury. J Neurotrauma 2023. [PMID: 37463057 DOI: 10.1089/neu.2023.0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
We previously described five trajectories of insomnia (each defined by a distinct pattern of insomnia severity over 12 months following traumatic brain injury [TBI]). Our objective in the present study was to estimate the association between insomnia trajectory status and trajectories of mental health and neurocognitive outcomes during the 12 months after TBI. In this study, participants included N = 2022 adults from the Federal Inter-agency Traumatic Brain Injury Repository database and Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study. The following outcome measures were assessed serially at 2 weeks, and 3, 6, and 12 months post-injury: Insomnia Severity Index, Patient Health Questionnaire, Post-Traumatic Stress Disorder (PTSD) Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), Patient Reported Outcomes Measurement Information System-Pain, and Quality of Life After Brain Injury-Overall Scale. Neurocognitive performance was assessed at 2 weeks, and 6 and 12 months using the Wechsler Adult Intelligence Scales Processing Speed Index and the Trails Making Test Parts A and B. Results indicated that greater insomnia severity was associated with greater abnormality in mental health, quality of life, and neuropsychological testing outcomes. The pattern of insomnia over time tracked the temporal pattern of all these outcomes for all but a very small number of participants. Notably, severe insomnia at 3 or 6 months post-TBI was a risk factor for poor recovery at 12 months post-injury. In conclusion, in this well-characterized sample of individuals with TBI, insomnia severity generally tracked severity of depression, pain, PTSD, quality of life, and neurocognitive outcomes over 12 months post-injury. More intensive sleep assessment is needed to elucidate the nature of these relationships and to help inform best strategies for intervention.
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Affiliation(s)
- Emerson M Wickwire
- Sleep Disorders Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jennifer S Albrecht
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Vincent F Capaldi
- Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Sonia Jain
- Biostatistics Research Center, Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, San Diego, California, USA
| | - Raquel C Gardner
- Department of Neurology, University of California, San Francisco, San Francisco, California, USA
| | - Michael T Smith
- Department of Psychiatry, Division of Behavioral Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Scott G Williams
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Department of Medicine, Fort Belvoir Community Hospital, Fort Belvoir, Virginia, USA
- Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Jacob Collen
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Sleep Disorders Center, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - David M Schnyer
- Department of Psychology, University of Texas Austin, Austin, Texas, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
| | - Lindsay D Nelson
- Departments of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Pratik Mukherjee
- Department of Radiology, University of California, San Francisco, San Francisco, California, USA
| | - Xiaoying Sun
- Biostatistics Research Center, Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, San Diego, California, USA
| | - J Kent Werner
- Department of Neurology, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Department of Neurology, Division of Behavioral Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Caterina B Mosti
- Department of Psychiatry, University of California, San Francisco, San Francisco, California, USA
| | - Amy J Markowitz
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Geoffrey T Manley
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, California, USA
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
| | - Andrew D Krystal
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, California, USA
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
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13
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Etemad LL, Yue JK, Barber J, Nelson LD, Bodien YG, Satris GG, Belton PJ, Madhok DY, Huie JR, Hamidi S, Tracey JX, Coskun BC, Wong JC, Yuh EL, Mukherjee P, Markowitz AJ, Huang MC, Tarapore PE, Robertson CS, Diaz-Arrastia R, Stein MB, Ferguson AR, Puccio AM, Okonkwo DO, Giacino JT, McCrea MA, Manley GT, Temkin NR, DiGiorgio AM. Longitudinal Recovery Following Repetitive Traumatic Brain Injury. JAMA Netw Open 2023; 6:e2335804. [PMID: 37751204 PMCID: PMC10523170 DOI: 10.1001/jamanetworkopen.2023.35804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 08/21/2023] [Indexed: 09/27/2023] Open
Abstract
Importance One traumatic brain injury (TBI) increases the risk of subsequent TBIs. Research on longitudinal outcomes of civilian repetitive TBIs is limited. Objective To investigate associations between sustaining 1 or more TBIs (ie, postindex TBIs) after study enrollment (ie, index TBIs) and multidimensional outcomes at 1 year and 3 to 7 years. Design, Setting, and Participants This cohort study included participants presenting to emergency departments enrolled within 24 hours of TBI in the prospective, 18-center Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study (enrollment years, February 2014 to July 2020). Participants who completed outcome assessments at 1 year and 3 to 7 years were included. Data were analyzed from September 2022 to August 2023. Exposures Postindex TBI(s). Main Outcomes and Measures Demographic and clinical factors, prior TBI (ie, preindex TBI), and functional (Glasgow Outcome Scale-Extended [GOSE]), postconcussive (Rivermead Post-Concussion Symptoms Questionnaire [RPQ]), psychological distress (Brief Symptom Inventory-18 [BSI-18]), depressive (Patient Health Questionnaire-9 [PHQ-9]), posttraumatic stress disorder (PTSD; PTSD Checklist for DSM-5 [PCL-5]), and health-related quality-of-life (Quality of Life After Brain Injury-Overall Scale [QOLIBRI-OS]) outcomes were assessed. Adjusted mean differences (aMDs) and adjusted relative risks are reported with 95% CIs. Results Of 2417 TRACK-TBI participants, 1572 completed the outcomes assessment at 1 year (1049 [66.7%] male; mean [SD] age, 41.6 [17.5] years) and 1084 completed the outcomes assessment at 3 to 7 years (714 [65.9%] male; mean [SD] age, 40.6 [17.0] years). At 1 year, a total of 60 participants (4%) were Asian, 255 (16%) were Black, 1213 (77%) were White, 39 (2%) were another race, and 5 (0.3%) had unknown race. At 3 to 7 years, 39 (4%) were Asian, 149 (14%) were Black, 868 (80%) were White, 26 (2%) had another race, and 2 (0.2%) had unknown race. A total of 50 (3.2%) and 132 (12.2%) reported 1 or more postindex TBIs at 1 year and 3 to 7 years, respectively. Risk factors for postindex TBI were psychiatric history, preindex TBI, and extracranial injury severity. At 1 year, compared with those without postindex TBI, participants with postindex TBI had worse functional recovery (GOSE score of 8: adjusted relative risk, 0.57; 95% CI, 0.34-0.96) and health-related quality of life (QOLIBRI-OS: aMD, -15.9; 95% CI, -22.6 to -9.1), and greater postconcussive symptoms (RPQ: aMD, 8.1; 95% CI, 4.2-11.9), psychological distress symptoms (BSI-18: aMD, 5.3; 95% CI, 2.1-8.6), depression symptoms (PHQ-9: aMD, 3.0; 95% CI, 1.5-4.4), and PTSD symptoms (PCL-5: aMD, 7.8; 95% CI, 3.2-12.4). At 3 to 7 years, these associations remained statistically significant. Multiple (2 or more) postindex TBIs were associated with poorer outcomes across all domains. Conclusions and Relevance In this cohort study of patients with acute TBI, postindex TBI was associated with worse symptomatology across outcome domains at 1 year and 3 to 7 years postinjury, and there was a dose-dependent response with multiple postindex TBIs. These results underscore the critical need to provide TBI prevention, education, counseling, and follow-up care to at-risk patients.
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Affiliation(s)
- Leila L. Etemad
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - John K. Yue
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Jason Barber
- Departments of Neurological Surgery and Biostatistics, University of Washington, Seattle
| | - Lindsay D. Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
- Department of Neurology, Medical College of Wisconsin, Milwaukee
| | - Yelena G. Bodien
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, Massachusetts
| | - Gabriela G. Satris
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Patrick J. Belton
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Debbie Y. Madhok
- Department of Emergency Medicine, University of California, San Francisco
| | - J. Russell Huie
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Sabah Hamidi
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Joye X. Tracey
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Bukre C. Coskun
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Justin C. Wong
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Esther L. Yuh
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
- Department of Radiology and Biomedical Imaging, University of California, San Francisco
| | - Pratik Mukherjee
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
- Department of Radiology and Biomedical Imaging, University of California, San Francisco
| | - Amy J. Markowitz
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Michael C. Huang
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Phiroz E. Tarapore
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | | | | | - Murray B. Stein
- Department of Psychiatry, University of California, San Diego
| | - Adam R. Ferguson
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
- San Francisco Veterans Affairs Healthcare System, San Francisco, California
| | - Ava M. Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Joseph T. Giacino
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, Massachusetts
| | - Michael A. McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
- Department of Neurology, Medical College of Wisconsin, Milwaukee
| | - Geoffrey T. Manley
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Nancy R. Temkin
- Departments of Neurological Surgery and Biostatistics, University of Washington, Seattle
| | - Anthony M. DiGiorgio
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
- Institute of Health Policy Studies, University of California, San Francisco
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Devoto C, Vorn R, Mithani S, Meier TB, Lai C, Broglio SP, McAllister T, Giza CC, Huber D, Harezlak J, Cameron KL, McGinty G, Jackson J, Guskiewicz K, Mihalik JP, Brooks A, Duma S, Rowson S, Nelson LD, Pasquina P, Turtzo C, Latour L, McCrea MA, Gill JM. Plasma phosphorylated tau181 as a biomarker of mild traumatic brain injury: findings from THINC and NCAA-DoD CARE Consortium prospective cohorts. Front Neurol 2023; 14:1202967. [PMID: 37662031 PMCID: PMC10470112 DOI: 10.3389/fneur.2023.1202967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 07/18/2023] [Indexed: 09/05/2023] Open
Abstract
Objective The aim of this study was to investigate phosphorylated tau (p-tau181) protein in plasma in a cohort of mild traumatic brain injury (mTBI) patients and a cohort of concussed athletes. Methods This pilot study comprised two independent cohorts. The first cohort-part of a Traumatic Head Injury Neuroimaging Classification (THINC) study-with a mean age of 46 years was composed of uninjured controls (UIC, n = 30) and mTBI patients (n = 288) recruited from the emergency department with clinical computed tomography (CT) and research magnetic resonance imaging (MRI) findings. The second cohort-with a mean age of 19 years-comprised 133 collegiate athletes with (n = 112) and without (n = 21) concussions. The participants enrolled in the second cohort were a part of a multicenter, prospective, case-control study conducted by the NCAA-DoD Concussion Assessment, Research and Education (CARE) Consortium at six CARE Advanced Research Core (ARC) sites between 2015 and 2019. Blood was collected within 48 h of injury for both cohorts. Plasma concentration (pg/ml) of p-tau181 was measured using the Single Molecule Array ultrasensitive assay. Results Concentrations of plasma p-tau181 in both cohorts were significantly elevated compared to controls within 48 h of injury, with the highest concentrations of p-tau181 within 18 h of injury, with an area under the curve (AUC) of 0.690-0.748, respectively, in distinguishing mTBI patients and concussed athletes from controls. Among the mTBI patients, the levels of plasma p-tau181 were significantly higher in patients with positive neuroimaging (either CT+/MRI+, n = 74 or CT-/MRI+, n = 89) compared to mTBI patients with negative neuroimaging (CT-/MRI-, n = 111) findings and UIC (P-values < 0.05). Conclusion These findings indicate that plasma p-tau181 concentrations likely relate to brain injury, with the highest levels in patients with neuroimaging evidence of injury. Future research is needed to replicate and validate this protein assay's performance as a possible early diagnostic biomarker for mTBI/concussions.
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Affiliation(s)
- Christina Devoto
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States
| | - Rany Vorn
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
- School of Nursing, Johns Hopkins University, Baltimore, MD, United States
| | - Sara Mithani
- School of Nursing, University of Texas Health at San Antonio, San Antonio, TX, United States
| | - Timothy B. Meier
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Chen Lai
- Center for Neuroscience and Regenerative Medicine, Uniformed Services University and Health Science, Bethesda, MD, United States
| | - Steven P. Broglio
- Michigan Concussion Center, University of Michigan, Ann Arbor, MI, United States
| | - Thomas McAllister
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Christopher C. Giza
- Departments of Pediatrics and Neurosurgery, UCLA Steve Tisch BrainSPORT Program, University of California, Los Angeles, Los Angeles, CA, United States
| | - Daniel Huber
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Jaroslaw Harezlak
- Department of Epidemiology and Biostatistics School of Public Health-Bloomington, Indiana University, Bloomington, IN, United States
| | - Kenneth L. Cameron
- John A. Feagin Sports Medicine Fellowship, Keller Army Hospital, West Point, NY, United States
| | - Gerald McGinty
- United States Air Force Academy, Colorado Springs, CO, United States
| | - Jonathan Jackson
- United States Air Force Academy, Colorado Springs, CO, United States
| | - Kevin Guskiewicz
- Matthew Gfeller Center, Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Jason P. Mihalik
- Matthew Gfeller Center, Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Alison Brooks
- Department of Orthopedics and Sports Medicine, University of Wisconsin, Madison, WI, United States
| | - Stefan Duma
- Department of Biomedical Engineering, Virginia Tech, Blacksburg, VA, United States
| | - Steven Rowson
- Department of Biomedical Engineering, Virginia Tech, Blacksburg, VA, United States
| | - Lindsay D. Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Paul Pasquina
- Center for Neuroscience and Regenerative Medicine, Uniformed Services University and Health Science, Bethesda, MD, United States
| | - Christine Turtzo
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
| | - Lawrence Latour
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
| | - Michael A. McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Jessica M. Gill
- School of Nursing, Johns Hopkins University, Baltimore, MD, United States
- Department of Neurology, Johns Hopkins University, Baltimore, MD, United States
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Brett BL, Temkin N, Barber JK, Okonkwo DO, Stein M, Bodien YG, Corrigan J, Diaz-Arrastia R, Giacino JT, McCrea MA, Manley GT, Nelson LD. Long-term Multidomain Patterns of Change After Traumatic Brain Injury: A TRACK-TBI LONG Study. Neurology 2023; 101:e740-e753. [PMID: 37344231 PMCID: PMC10437015 DOI: 10.1212/wnl.0000000000207501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 04/21/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Traumatic brain injury (TBI) may be a chronic condition carrying risk of future sequelae; few prospective studies examine long-term postinjury outcomes. We examined the prevalence of functional, cognitive, and psychiatric change outcomes from 1 to 7 years postinjury. METHODS Transforming Research and Clinical Knowledge in TBI LONG (TRACK-TBI LONG) participants were prospectively enrolled within 24 hours of injury and followed up to 1 year postinjury; a subset participated in long-term follow-up from 2 to 7 years postinjury. Reliable change thresholds for the Brief Test of Adult Cognition by Telephone General Composite (cognition) and Brief Symptom Inventory (BSI)-18 (psychiatric) were derived from orthopedic trauma controls (OTCs). Multiple assessments were completed (postinjury baseline assessment and 2 or 3 visits 2-7 years postinjury) within a sample subset. Change was assessed for functional outcome (Glasgow Outcome Scale-Extended [GOSE]) and self-report/informant report of decline. Prevalence ratios for outcomes classified as stable, improved, and declined were reported individually and collectively. The Fisher exact test and log-binomial regression models examined factors associated with decline and improvement. RESULTS Of the sample (N = 1,264; mild TBI [mTBI], Glasgow Coma Scale [GCS] 13-15, n = 917; moderate-to-severe TBI [msTBI], GCS 3-12, n = 193; or OTC n = 154), "stable" was the most prevalent outcome. Functional outcome showed the highest rates of decline, regardless of TBI severity (mild = 29%; moderate/severe = 23%). When measures were collectively considered, rates of decline included mTBI (21%), msTBI (26%), and OTC (15%). Age and preinjury employment status were associated with functional decline (per 10 years; relative risk [RR] 1.16, 95% CI 1.07-1.25, p < 0.001; higher in retired/disabled/not working vs full-time/part-time; RR 1.81, 95% CI 1.33-2.45, respectively) in the mTBI group. Improvement in functional recovery 2-7 years postinjury was associated with higher BSI scores (per 5 points; RR 1.11, 95% CI 1.04-1.18, p = 0.002) and GOSE score of 5-7 (GOSE = 8 as reference; RR 2.64, 95% CI 1.75-3.97, p < 0.001). Higher BSI scores and identifying as Black (RR 2.28, 95% CI 1.59-3.25, p < 0.001) were associated with a greater likelihood of improved psychiatric symptoms in mTBI (RR 1.21, 95% CI 1.14-1.29, p < 0.001). A greater likelihood of cognitive improvement was observed among those with higher educational attainment in msTBI (per 4 years; RR 2.61, 95% CI 1.43-4.79, p = 0.002). DISCUSSION Function across domains at 1-year postinjury, a common recovery benchmark, undergoes change across the subsequent 6 years. Results support consideration of TBI as a chronic evolving condition and suggest continued monitoring, rehabilitation, and support is required to optimize long-term independence and quality of life.
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Affiliation(s)
- Benjamin L Brett
- From the Medical College of Wisconsin (B.L.B., M.A.M., L.D.N.), Milwaukee; University of Washington (N.T., J.K.B.), Seattle; University of Pittsburgh Medical Center (D.O.O.), PA; University of California San Diego (M.S.), La Jolla; Massachusetts General Hospital and Harvard Medical School (Y.G.B., J.T.G.), Boston; The Ohio State University Wexner Medical Center (J.C.), Columbus; University of Pennsylvania (R.D.-A.), Philadelphia; and University of California, San Francisco (G.T.M.).
| | - Nancy Temkin
- From the Medical College of Wisconsin (B.L.B., M.A.M., L.D.N.), Milwaukee; University of Washington (N.T., J.K.B.), Seattle; University of Pittsburgh Medical Center (D.O.O.), PA; University of California San Diego (M.S.), La Jolla; Massachusetts General Hospital and Harvard Medical School (Y.G.B., J.T.G.), Boston; The Ohio State University Wexner Medical Center (J.C.), Columbus; University of Pennsylvania (R.D.-A.), Philadelphia; and University of California, San Francisco (G.T.M.)
| | - Jason K Barber
- From the Medical College of Wisconsin (B.L.B., M.A.M., L.D.N.), Milwaukee; University of Washington (N.T., J.K.B.), Seattle; University of Pittsburgh Medical Center (D.O.O.), PA; University of California San Diego (M.S.), La Jolla; Massachusetts General Hospital and Harvard Medical School (Y.G.B., J.T.G.), Boston; The Ohio State University Wexner Medical Center (J.C.), Columbus; University of Pennsylvania (R.D.-A.), Philadelphia; and University of California, San Francisco (G.T.M.)
| | - David O Okonkwo
- From the Medical College of Wisconsin (B.L.B., M.A.M., L.D.N.), Milwaukee; University of Washington (N.T., J.K.B.), Seattle; University of Pittsburgh Medical Center (D.O.O.), PA; University of California San Diego (M.S.), La Jolla; Massachusetts General Hospital and Harvard Medical School (Y.G.B., J.T.G.), Boston; The Ohio State University Wexner Medical Center (J.C.), Columbus; University of Pennsylvania (R.D.-A.), Philadelphia; and University of California, San Francisco (G.T.M.)
| | - Murray Stein
- From the Medical College of Wisconsin (B.L.B., M.A.M., L.D.N.), Milwaukee; University of Washington (N.T., J.K.B.), Seattle; University of Pittsburgh Medical Center (D.O.O.), PA; University of California San Diego (M.S.), La Jolla; Massachusetts General Hospital and Harvard Medical School (Y.G.B., J.T.G.), Boston; The Ohio State University Wexner Medical Center (J.C.), Columbus; University of Pennsylvania (R.D.-A.), Philadelphia; and University of California, San Francisco (G.T.M.)
| | - Yelena G Bodien
- From the Medical College of Wisconsin (B.L.B., M.A.M., L.D.N.), Milwaukee; University of Washington (N.T., J.K.B.), Seattle; University of Pittsburgh Medical Center (D.O.O.), PA; University of California San Diego (M.S.), La Jolla; Massachusetts General Hospital and Harvard Medical School (Y.G.B., J.T.G.), Boston; The Ohio State University Wexner Medical Center (J.C.), Columbus; University of Pennsylvania (R.D.-A.), Philadelphia; and University of California, San Francisco (G.T.M.)
| | - John Corrigan
- From the Medical College of Wisconsin (B.L.B., M.A.M., L.D.N.), Milwaukee; University of Washington (N.T., J.K.B.), Seattle; University of Pittsburgh Medical Center (D.O.O.), PA; University of California San Diego (M.S.), La Jolla; Massachusetts General Hospital and Harvard Medical School (Y.G.B., J.T.G.), Boston; The Ohio State University Wexner Medical Center (J.C.), Columbus; University of Pennsylvania (R.D.-A.), Philadelphia; and University of California, San Francisco (G.T.M.)
| | - Ramon Diaz-Arrastia
- From the Medical College of Wisconsin (B.L.B., M.A.M., L.D.N.), Milwaukee; University of Washington (N.T., J.K.B.), Seattle; University of Pittsburgh Medical Center (D.O.O.), PA; University of California San Diego (M.S.), La Jolla; Massachusetts General Hospital and Harvard Medical School (Y.G.B., J.T.G.), Boston; The Ohio State University Wexner Medical Center (J.C.), Columbus; University of Pennsylvania (R.D.-A.), Philadelphia; and University of California, San Francisco (G.T.M.)
| | - Joseph T Giacino
- From the Medical College of Wisconsin (B.L.B., M.A.M., L.D.N.), Milwaukee; University of Washington (N.T., J.K.B.), Seattle; University of Pittsburgh Medical Center (D.O.O.), PA; University of California San Diego (M.S.), La Jolla; Massachusetts General Hospital and Harvard Medical School (Y.G.B., J.T.G.), Boston; The Ohio State University Wexner Medical Center (J.C.), Columbus; University of Pennsylvania (R.D.-A.), Philadelphia; and University of California, San Francisco (G.T.M.)
| | - Michael A McCrea
- From the Medical College of Wisconsin (B.L.B., M.A.M., L.D.N.), Milwaukee; University of Washington (N.T., J.K.B.), Seattle; University of Pittsburgh Medical Center (D.O.O.), PA; University of California San Diego (M.S.), La Jolla; Massachusetts General Hospital and Harvard Medical School (Y.G.B., J.T.G.), Boston; The Ohio State University Wexner Medical Center (J.C.), Columbus; University of Pennsylvania (R.D.-A.), Philadelphia; and University of California, San Francisco (G.T.M.)
| | - Geoffrey T Manley
- From the Medical College of Wisconsin (B.L.B., M.A.M., L.D.N.), Milwaukee; University of Washington (N.T., J.K.B.), Seattle; University of Pittsburgh Medical Center (D.O.O.), PA; University of California San Diego (M.S.), La Jolla; Massachusetts General Hospital and Harvard Medical School (Y.G.B., J.T.G.), Boston; The Ohio State University Wexner Medical Center (J.C.), Columbus; University of Pennsylvania (R.D.-A.), Philadelphia; and University of California, San Francisco (G.T.M.)
| | - Lindsay D Nelson
- From the Medical College of Wisconsin (B.L.B., M.A.M., L.D.N.), Milwaukee; University of Washington (N.T., J.K.B.), Seattle; University of Pittsburgh Medical Center (D.O.O.), PA; University of California San Diego (M.S.), La Jolla; Massachusetts General Hospital and Harvard Medical School (Y.G.B., J.T.G.), Boston; The Ohio State University Wexner Medical Center (J.C.), Columbus; University of Pennsylvania (R.D.-A.), Philadelphia; and University of California, San Francisco (G.T.M.)
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Nelson LD. Rosalind Franklin Society Proudly Announces the 2022 Award Recipient for Neurotrauma Reports. Neurotrauma Rep 2023; 4:1. [PMID: 37497474 PMCID: PMC10366298 DOI: 10.1089/neur.2023.29003.rfs2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023] Open
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Musacchio S, Kallenbach MD, Huber DL, Raff H, Johnson BD, Leddy J, McCrea MA, Meier TB, Nelson LD. Salivary Cortisol Dynamics After Mild Traumatic Brain Injury. J Head Trauma Rehabil 2023; 38:E318-E327. [PMID: 36696236 PMCID: PMC10329977 DOI: 10.1097/htr.0000000000000855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To assess mild traumatic brain injury (mTBI)-related alterations in baseline (resting) salivary cortisol and cortisol reactivity to cognitive and exercise stressors, which are frequently encountered during mTBI rehabilitation and recovery. SETTING Persons with mTBI were recruited from a level 1 trauma center emergency department. Uninjured controls (UCs) were recruited from the community. PARTICIPANTS Participants were 37 individuals with mTBI and 24 UCs. All patients with mTBI were enrolled at 7 ± 3 days post-injury, met the American Congress of Rehabilitation Medicine definition of mTBI, and had no acute intracranial findings on clinical neuroimaging (if performed). DESIGN A prospective cohort study design was used. All participants provided saliva samples 10 times during each of 2 visits spaced 3 weeks apart (1 week and 1 month post-injury for the mTBI group). Each visit included baseline saliva sampling and sampling to evaluate reactivity to a cognitive stressor (Paced Auditory Serial Addition Test) and physical stressor (Buffalo Concussion Treadmill Test [BCTT]). MAIN OUTCOME MEASURE Natural log-transformed salivary cortisol was measured by enzyme immunoassay. Cortisol was predicted using a linear mixed-effects model by group (mTBI and UC), visit (1 week and 1 month), and saliva sample. RESULTS Mean salivary cortisol was higher in the mTBI group (1.67 nmol/L [95% CI 1.42-1.72]) than in controls (1.30 nmol/L [1.12-1.47]), without an mTBI × time interaction. At 1 week, the mTBI group had greater cortisol reactivity in response to the BCTT. CONCLUSIONS Higher cortisol in individuals with mTBI at 1 week and 1 month post-injury extends previous findings into the subacute recovery period. Furthermore, the mTBI group demonstrated a greater cortisol response to mild-to-moderate aerobic exercise (BCTT) at 1 week post-injury. Given the increasing role of exercise in mTBI rehabilitation, further research is warranted to replicate these findings and identify the clinical implications, if any, of enhanced hypothalamic-pituitary-adrenal axis responses to exercise in civilians with recent mTBI.
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Affiliation(s)
- Sophia Musacchio
- Departments of Neurosurgery (Ms Musacchio, Mx Kallenbach, Mr Huber, and Drs McCrea, Meier, and Nelson) and Medicine, Surgery, and Physiology (Dr Raff), Medical College of Wisconsin, Milwaukee; Endocrine Research Laboratory, Aurora St Luke's Medical Center, Advocate Aurora Research Institute, Milwaukee, Wisconsin (Dr Raff); Department of Kinesiology, Indiana University, Bloomington (Dr Johnson); and UBMD Orthopaedics and Sports Medicine, and SUNY Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York (Dr Leddy)
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18
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Vorn R, Devoto C, Meier TB, Lai C, Yun S, Broglio SP, Mithani S, McAllister TW, Giza CC, Kim HS, Huber D, Harezlak J, Cameron KL, McGinty G, Jackson J, Guskiewicz KM, Mihalik JP, Brooks A, Duma S, Rowson S, Nelson LD, Pasquina P, McCrea MA, Gill JM. Are EPB41 and alpha-synuclein diagnostic biomarkers of sport-related concussion? Findings from the NCAA and Department of Defense CARE Consortium. J Sport Health Sci 2023; 12:379-387. [PMID: 36403906 DOI: 10.1016/j.jshs.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 07/15/2022] [Accepted: 10/08/2022] [Indexed: 05/17/2023]
Abstract
BACKGROUND Current protein biomarkers are only moderately predictive at identifying individuals with mild traumatic brain injury or concussion. Therefore, more accurate diagnostic markers are needed for sport-related concussion. METHODS This was a multicenter, prospective, case-control study of athletes who provided blood samples and were diagnosed with a concussion or were a matched non-concussed control within the National Collegiate Athletic Association-Department of Defense Concussion Assessment, Research, and Education Consortium conducted between 2015 and 2019. The blood was collected within 48 h of injury to identify protein abnormalities at the acute and subacute timepoints. Athletes with concussion were divided into 6 h post-injury (0-6 h post-injury) and after 6 h post-injury (7-48 h post-injury) groups. We applied a highly multiplexed proteomic technique that used a DNA aptamers assay to target 1305 proteins in plasma samples from athletes with and without sport-related concussion. RESULTS A total of 140 athletes with concussion (79.3% males; aged 18.71 ± 1.10 years, mean ± SD) and 21 non-concussed athletes (76.2% males; 19.14 ± 1.10 years) were included in this study. We identified 338 plasma proteins that significantly differed in abundance (319 upregulated and 19 downregulated) in concussed athletes compared to non-concussed athletes. The top 20 most differentially abundant proteins discriminated concussed athletes from non-concussed athletes with an area under the curve (AUC) of 0.954 (95% confidence interval: 0.922‒0.986). Specifically, after 6 h of injury, the individual AUC of plasma erythrocyte membrane protein band 4.1 (EPB41) and alpha-synuclein (SNCA) were 0.956 and 0.875, respectively. The combination of EPB41 and SNCA provided the best AUC (1.000), which suggests this combination of candidate plasma biomarkers is the best for diagnosing concussion in athletes after 6 h of injury. CONCLUSION Our data suggest that proteomic profiling may provide novel diagnostic protein markers and that a combination of EPB41 and SNCA is the most predictive biomarker of concussion after 6 h of injury.
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Affiliation(s)
- Rany Vorn
- Johns Hopkins School of Nursing and Medicine, Baltimore, MD 21205, USA; National Institutes of Health, Bethesda, MD 20892, USA
| | | | - Timothy B Meier
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Chen Lai
- National Institutes of Health, Bethesda, MD 20892, USA
| | - Sijung Yun
- Predictiv Care, Inc., Mountain View, CA 94086, USA
| | - Steven P Broglio
- Michigan Concussion Center, University of Michigan, Ann Arbor, MI 48109, USA
| | - Sara Mithani
- National Institutes of Health, Bethesda, MD 20892, USA
| | - Thomas W McAllister
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Christopher C Giza
- Departments of Pediatrics and Neurosurgery, University of California at Los Angeles (UCLA), Los Angeles, CA 90024, USA
| | - Hyung-Suk Kim
- National Institutes of Health, Bethesda, MD 20892, USA
| | - Daniel Huber
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Jaroslaw Harezlak
- Department of Epidemiology and Biostatistics School of Public Health - Bloomington, Indiana University, Bloomington, IN 47405, USA
| | - Kenneth L Cameron
- John A. Feagin Sports Medicine Fellowship, Keller Army Community Hospital, West Point, NY 10996, USA
| | - Gerald McGinty
- United States Air Force Academy, Colorado Springs, CO 80840, USA
| | - Jonathan Jackson
- United States Air Force Academy, Colorado Springs, CO 80840, USA
| | - Kevin M Guskiewicz
- Mathew Gfeller Center, Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, USA
| | - Jason P Mihalik
- Mathew Gfeller Center, Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, USA
| | - Alison Brooks
- Department of Orthopedics, Division of Sports Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53705, USA
| | - Stefan Duma
- Department of Biomedical Engineering and Mechanics, Virginia Tech, Blacksburg, VA 24061, USA
| | - Steven Rowson
- Department of Biomedical Engineering and Mechanics, Virginia Tech, Blacksburg, VA 24061, USA
| | - Lindsay D Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Paul Pasquina
- Center for Neuroscience & Regenerative Medicine, Uniformed Services University, Bethesda, MD 20814, USA
| | - Michael A McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Jessica M Gill
- Johns Hopkins School of Nursing and Medicine, Baltimore, MD 21205, USA.
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Abstract
Mild traumatic brain injury (mTBI) is a major public health concern. Cerebrovascular alterations play a significant role in the evolution of injury sequelae and in the process of post-traumatic brain repair. Arterial spin labeling (ASL) is an advanced perfusion magnetic resonance imaging technique that permits noninvasive quantification of cerebral blood flow (CBF). This is the first systematic review of ASL research findings in patients with mTBI. Our approach followed the American Academy of Neurology (AAN) and PRISMA guidelines. We searched Ovid/MEDLINE, Web of Science, Scopus, and the Cochrane Index for relevant articles published as of February 20, 2020. Full-text results were combined into Rayyan software for further evaluation. Data extraction, including risk of bias ratings, was performed using American Academy of Neurology's four-tiered classification scheme. Twenty-three articles met inclusion criteria comprising data on up to 566 mTBI patients and 654 control subjects. Of the 23 studies, 18 reported some type of regional CBF abnormality in mTBI patients at rest or during a cognitive task, with more findings of decreased than increased CBF. The evidence supports the conclusion that mTBI likely causes ASL-derived CBF anomalies. However, synthesis of findings was challenging due to substantial methodological variations across studies and few studies with low risk of bias. Thus, larger-scale prospective cohort studies are needed to more definitively chart the course of CBF changes in humans after mTBI and to understand how individual difference factors contribute to post-injury CBF changes.
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Affiliation(s)
- Yang Wang
- Department of Radiology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA.
| | - Hannah M Bartels
- Department of Neurosurgery, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI, 53226, USA
| | - Lindsay D Nelson
- Department of Neurosurgery, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI, 53226, USA
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Abstract
OBJECTIVE To test the hypotheses that (1) higher neighborhood disadvantage is associated with greater injury-related symptom severity in civilians with mild traumatic brain injury (mTBI) and (2) neighborhood disadvantage remains predictive after controlling for other established predictors. SETTING Level 1 trauma center and affiliated academic medical center. PARTICIPANTS N = 171 individuals with mTBI. DESIGN Prospective cohort study. MAIN MEASURES Rivermead Post Concussion Symptoms Questionnaire (RPQ) total score assessed less than 24 hours and at 2 weeks, 3 months, and 6 months postinjury. Linear mixed-effects models were used to assess the relationship between predictor variables and mTBI-related symptom burden (RPQ score). Neighborhood disadvantage was quantified by the Area Deprivation Index (ADI), a composite of 17 markers of socioeconomic position (SEP) scored at the census block group level. RESULTS Individuals in the upper ADI quartile of the national distribution displayed higher RPQ symptoms than those in the lower 3 quartiles ( P < .001), with a nonsignificant ADI × visit interaction ( P = .903). In a multivariable model, the effect of ADI remained significant ( P = .034) after adjusting for demographics, individual SEP, and injury factors. Other unique predictors in the multivariable model were gender (gender × visit P = .035), health insurance type ( P = .017), and injury-related litigation ( P = .012). CONCLUSION Neighborhood disadvantage as quantified by the ADI is robustly associated with greater mTBI-related symptom burden throughout the first 6 months postinjury. That the effect of ADI remained after controlling for demographics, individual SEP, and injury characteristics implies that neighborhood disadvantage is an important, understudied factor contributing to clinical recovery from mTBI.
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Affiliation(s)
- Tessa Miller
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
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Nelson LD, Temkin NR, Barber J, Brett BL, Okonkwo DO, McCrea MA, Giacino JT, Bodien YG, Robertson C, Corrigan JD, Diaz-Arrastia R, Markowitz AJ, Manley GT. Functional Recovery, Symptoms, and Quality of Life 1 to 5 Years After Traumatic Brain Injury. JAMA Netw Open 2023; 6:e233660. [PMID: 36939699 PMCID: PMC10028488 DOI: 10.1001/jamanetworkopen.2023.3660] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 01/21/2023] [Indexed: 03/21/2023] Open
Abstract
Importance Many level I trauma center patients experience clinical sequelae at 1 year following traumatic brain injury (TBI). Longer-term outcome data are needed to develop better monitoring and rehabilitation services. Objective To examine functional recovery, TBI-related symptoms, and quality of life from 1 to 5 years postinjury. Design, Setting, and Participants This cohort study enrolled trauma patients across 18 US level I trauma centers between 2014 and 2018. Eligible participants were enrolled within 24 hours of injury and followed up to 5 years postinjury. Data were analyzed January 2023. Exposures Mild TBI (mTBI), moderate-severe TBI (msTBI), or orthopedic traumatic controls (OTC). Main Outcomes and Measures Functional independence (Glasgow Outcome Scale-Extended [GOSE] score 5 or higher), complete functional recovery (GOSE score, 8), better (ie, lower) TBI-related symptom burden (Rivermead Post Concussion Symptoms Questionnaire score of 15 or lower), and better (ie, higher) health-related quality of life (Quality of Life After Brain Injury Scale-Overall Scale score 52 or higher); mortality was analyzed as a secondary outcome. Results A total 1196 patients were included in analysis (mean [SD] age, 40.8 [16.9] years; 781 [65%] male; 158 [13%] Black, 965 [81%] White). mTBI and OTC groups demonstrated stable, high rates of functional independence (98% to 100% across time). While odds of independence were lower among msTBI survivors, the majority were independent at 1 year (72%), and this proportion increased over time (80% at 5 years; group × year, P = .005; independence per year: odds ratio [OR] for msTBI, 1.28; 95% CI, 1.03-1.58; OR for mTBI, 0.81; 95% CI, 0.64-1.03). For other outcomes, group differences at 1 year remained stable over time (group × year, P ≥ .44). Odds of complete functional recovery remained lower for persons with mTBI vs OTC (OR, 0.39; 95% CI, 0.28-0.56) and lower for msTBI vs mTBI (OR, 0.34; 95% CI, 0.24-0.48). Odds of better TBI-related symptom burden and quality of life were similar for both TBI subgroups and lower than OTCs. Mortality between 1 and 5 years was higher for msTBI (5.5%) than mTBI (1.5%) and OTC (0.7%; P = .02). Conclusions and Relevance In this cohort study, patients with previous msTBI displayed increased independence over 5 years; msTBI was also associated with increased mortality. These findings, in combination with the persistently elevated rates of unfavorable outcomes in mTBI vs controls imply that more monitoring and rehabilitation are needed for TBI.
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Affiliation(s)
| | | | | | | | - David O. Okonkwo
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Joseph T. Giacino
- Massachusetts General Hospital and Harvard Medical School, Boston
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts
| | - Yelena G. Bodien
- Massachusetts General Hospital and Harvard Medical School, Boston
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts
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22
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Bodien YG, Barber J, Taylor SR, Boase K, Corrigan JD, Dikmen S, Gardner RC, Kramer JH, Levin H, Machamer J, McAllister T, Nelson LD, Ngwenya LB, Sherer M, Stein MB, Vassar M, Whyte J, Yue JK, Markowitz A, McCrea MA, Manley GT, Temkin N, Giacino JT. Feasibility and Utility of a Flexible Outcome Assessment Battery for Longitudinal Traumatic Brain Injury Research: A TRACK-TBI Study. J Neurotrauma 2023; 40:337-348. [PMID: 36097759 PMCID: PMC9902043 DOI: 10.1089/neu.2022.0141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The effects of traumatic brain injury (TBI) are difficult to measure in longitudinal cohort studies, because disparate pre-injury characteristics and injury mechanisms produce variable impairment profiles and recovery trajectories. In preparation for the Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study, which followed patients with injuries ranging from uncomplicated mild TBI to coma, we designed a multi-dimensional Flexible outcome Assessment Battery (FAB). The FAB relies on a decision-making algorithm that assigns participants to a Comprehensive (CAB) or Abbreviated Assessment Battery (AAB) and guides test selection across all phases of recovery. To assess feasibility of the FAB, we calculated the proportion of participants followed at 2 weeks (2w) and at 3, 6, and 12 months (3m, 6m, 12m) post-injury who completed the FAB and received valid scores. We evaluated utility of the FAB by examining differences in 6m and 12m Glasgow Outcome Scale-Extended (GOSE) scores between participant subgroups derived from the FAB-enabled versus traditional approach to outcome assessment applied at 2w. Among participants followed at 2w (n = 2094), 3m (n = 1871), 6m (n = 1736), and 12m (n = 1607) post-injury, 95-99% received valid completion scores on the FAB, in full or in part, either in person or by telephone. Level of function assessed by the FAB-enabled approach at 2w was associated with 6m and 12m GOSE scores (proportional odds p < 0.001). These findings suggest that the participant classification methodology afforded by the FAB may enable more effective data collection to improve detection of natural history changes and TBI treatment effects.
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Affiliation(s)
- Yelena G. Bodien
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
| | - Jason Barber
- University of Washington, Seattle, Washington, USA
| | - Sabrina R. Taylor
- University of California, San Francisco, San Francisco, California, USA
| | - Kim Boase
- University of Washington, Seattle, Washington, USA
| | | | | | - Raquel C. Gardner
- University of California, San Francisco, San Francisco, California, USA
| | - Joel H. Kramer
- University of California, San Francisco, San Francisco, California, USA
| | | | | | - Thomas McAllister
- University of Indiana School of Medicine, Indianapolis, Indiana, USA
| | | | | | - Mark Sherer
- Baylor College of Medicine, Houston, Texas, USA
- TIRR Memorial Hermann, Houston, Texas, USA
| | - Murray B. Stein
- University of California San Diego, La Jolla, California, USA
| | - Mary Vassar
- University of California, San Francisco, San Francisco, California, USA
| | - John Whyte
- Moss Rehabilitation Research Institute, Elkins Park, Pennsylvania, USA
| | - John K. Yue
- University of California, San Francisco, San Francisco, California, USA
| | - Amy Markowitz
- University of California, San Francisco, San Francisco, California, USA
| | | | | | - Nancy Temkin
- University of Washington, Seattle, Washington, USA
| | - Joseph T. Giacino
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
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23
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Stein MB, Jain S, Parodi L, Choi KW, Maihofer AX, Nelson LD, Mukherjee P, Sun X, He F, Okonkwo DO, Giacino JT, Korley FK, Vassar MJ, Robertson CS, McCrea MA, Temkin N, Markowitz AJ, Diaz-Arrastia R, Rosand J, Manley GT, Duhaime AC, Ferguson AR, Gopinath S, Grandhi R, Madden C, Merchant R, Schnyer D, Taylor SR, Yue JK, Zafonte R. Polygenic risk for mental disorders as predictors of posttraumatic stress disorder after mild traumatic brain injury. Transl Psychiatry 2023; 13:24. [PMID: 36693822 PMCID: PMC9873804 DOI: 10.1038/s41398-023-02313-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/03/2023] [Accepted: 01/06/2023] [Indexed: 01/26/2023] Open
Abstract
Many patients with mild traumatic brain injury (mTBI) are at risk for mental health problems such as posttraumatic stress disorder (PTSD). The objective of this study was to determine whether the polygenic risk for PTSD (or for related mental health disorders or traits including major depressive disorder [MDD] and neuroticism [NEU]) was associated with an increased likelihood of PTSD in the aftermath of mTBI. We used data from individuals of European ancestry with mTBI enrolled in TRACK-TBI (n = 714), a prospective longitudinal study of level 1 trauma center patients. One hundred and sixteen mTBI patients (16.3%) had probable PTSD (PCL-5 score ≥33) at 6 months post-injury. We used summary statistics from recent GWAS studies of PTSD, MDD, and NEU to generate polygenic risk scores (PRS) for individuals in our sample. A multivariable model that included age, sex, pre-injury history of mental disorder, and cause of injury explained 7% of the variance in the PTSD outcome; the addition of the PTSD-PRS (and five ancestral principal components) significantly increased the variance explained to 11%. The adjusted odds of PTSD in the uppermost PTSD-PRS quintile was nearly four times higher (aOR = 3.71, 95% CI 1.80-7.65) than in the lowest PTSD-PRS quintile. There was no evidence of a statistically significant interaction between PTSD-PRS and prior history of mental disorder, indicating that PTSD-PRS had similar predictive utility among those with and without pre-injury psychiatric illness. When added to the model, neither MDD-PRS nor NEU-PRS were significantly associated with the PTSD outcome. These findings show that the risk for PTSD in the context of mTBI is, in part, genetically influenced. They also raise the possibility that an individual's PRS could be clinically actionable if used-possibly with other non-genetic predictors-to signal the need for enhanced follow-up and early intervention; this precision medicine approach needs to be prospectively studied.
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Affiliation(s)
- Murray B. Stein
- grid.266100.30000 0001 2107 4242Department of Psychiatry, University of California, San Diego, La Jolla, CA USA ,grid.266100.30000 0001 2107 4242School of Public Health, University of California, San Diego, La Jolla, CA USA ,grid.410371.00000 0004 0419 2708VA San Diego Healthcare System, San Diego, CA USA
| | - Sonia Jain
- grid.266100.30000 0001 2107 4242Biostatistics Research Center, Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla, CA USA
| | - Livia Parodi
- grid.32224.350000 0004 0386 9924Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA USA ,grid.32224.350000 0004 0386 9924McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA USA ,grid.66859.340000 0004 0546 1623Broad Institute of MIT and Harvard, Cambridge, MA USA
| | - Karmel W. Choi
- grid.66859.340000 0004 0546 1623Broad Institute of MIT and Harvard, Cambridge, MA USA ,grid.32224.350000 0004 0386 9924Department of Psychiatry, Massachusetts General Hospital, Boston, MA USA
| | - Adam X. Maihofer
- grid.266100.30000 0001 2107 4242Department of Psychiatry, University of California, San Diego, La Jolla, CA USA
| | - Lindsay D. Nelson
- grid.30760.320000 0001 2111 8460Departments of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI USA
| | - Pratik Mukherjee
- grid.266102.10000 0001 2297 6811Department of Radiology & Biomedical Imaging, UCSF, San Francisco, CA USA ,grid.266102.10000 0001 2297 6811Department of Bioengineering & Therapeutic Sciences, UCSF, San Francisco, CA USA
| | - Xiaoying Sun
- grid.266100.30000 0001 2107 4242Biostatistics Research Center, Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla, CA USA
| | - Feng He
- grid.266100.30000 0001 2107 4242Biostatistics Research Center, Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla, CA USA
| | - David O. Okonkwo
- grid.412689.00000 0001 0650 7433Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - Joseph T. Giacino
- grid.38142.3c000000041936754XDepartment of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA USA ,grid.416228.b0000 0004 0451 8771Spaulding Rehabilitation Hospital, Charlestown, MA USA
| | - Frederick K. Korley
- grid.214458.e0000000086837370Department of Emergency Medicine, University of Michigan, Ann Arbor, MI USA
| | - Mary J. Vassar
- grid.416732.50000 0001 2348 2960Brain and Spinal Cord Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA USA ,grid.266102.10000 0001 2297 6811Department of Neurological Surgery, UCSF, San Francisco, CA USA
| | - Claudia S. Robertson
- grid.39382.330000 0001 2160 926XDepartment of Neurosurgery, Baylor College of Medicine, Houston, TX USA
| | - Michael A. McCrea
- grid.30760.320000 0001 2111 8460Departments of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI USA
| | - Nancy Temkin
- grid.34477.330000000122986657Departments of Neurological Surgery and Biostatistics, University of Washington, Seattle, WA USA
| | - Amy J. Markowitz
- grid.416732.50000 0001 2348 2960Brain and Spinal Cord Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA USA
| | - Ramon Diaz-Arrastia
- grid.25879.310000 0004 1936 8972Department of Neurology, University of Pennsylvania, Philadelphia, PA USA
| | - Jonathan Rosand
- grid.32224.350000 0004 0386 9924Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA USA ,grid.32224.350000 0004 0386 9924McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA USA ,grid.66859.340000 0004 0546 1623Broad Institute of MIT and Harvard, Cambridge, MA USA
| | - Geoffrey T. Manley
- grid.416732.50000 0001 2348 2960Brain and Spinal Cord Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA USA ,grid.266102.10000 0001 2297 6811Department of Neurological Surgery, UCSF, San Francisco, CA USA
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24
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Thomas DG, Erpenbach H, Hickey RW, Waltzman D, Haarbauer-Krupa J, Nelson LD, Patterson CG, McCrea MA, Collins MW, Kontos AP. Implementation of active injury management (AIM) in youth with acute concussion: A randomized controlled trial. Contemp Clin Trials 2022; 123:106965. [PMID: 36252936 PMCID: PMC10924688 DOI: 10.1016/j.cct.2022.106965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/10/2022] [Accepted: 10/11/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Nearly 2 million youth seek acute medical care following concussion in the U.S. each year. Current standard of care recommends rest for the first 48 h after a concussion. However, research suggests that prolonged rest may lengthen recovery time especially for patients with certain risk profiles. Research indicates that physical activity and behavioral management interventions (sleep, stress management) may enhance recovery. To date, there is limited empirical evidence to inform acute (<72 h) concussion recommendations for physical activity and behavioral management in adolescents. OBJECTIVE To determine the effectiveness of physical activity and behavioral management for acute concussion in adolescents and young adults, and to evaluate the role of patient characteristics on treatment response. METHODS This multicenter prospective randomized controlled trial will determine which combination of physical activity and behavioral management is most effective for patients 11-24 years old who present to the emergency department or concussion clinic within 72 h of injury. Participants are randomized into: 1) rest, 2) physical activity, 3) mobile health application (mHealth) behavioral management, or 4) physical activity and mHealth app conditions. Assessments at enrollment, 3-5 days, 14 days, 1 month, and 2 months include: concussion symptoms, balance, vestibular-ocular and cognitive assessments, quality of life, and recovery time. Somatic symptoms and other risk factors are evaluated at enrollment. Compliance with treatment and symptoms are assessed daily using actigraph and daily self-report. The primary study outcome is symptoms at 14 days. CONCLUSION Prescribed physical activity and behavioral management may improve outcomes in youth following acute concussion.
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Affiliation(s)
- D G Thomas
- Medical College of Wisconsin, Department of Pediatrics, United States of America.
| | - H Erpenbach
- Medical College of Wisconsin, Department of Pediatrics, United States of America
| | - R W Hickey
- University of Pittsburgh, Department of Pediatrics, United States of America
| | - D Waltzman
- Centers for Disease Control and Prevention, United States of America
| | - J Haarbauer-Krupa
- Centers for Disease Control and Prevention, United States of America
| | - L D Nelson
- Medical College of Wisconsin, Department of Neurosurgery, United States of America
| | - C G Patterson
- University of Pittsburgh, Department of Physical Therapy, United States of America
| | - M A McCrea
- Medical College of Wisconsin, Department of Neurosurgery, United States of America
| | - M W Collins
- University of Pittsburgh, Department of Orthopedic Surgery, United States of America
| | - A P Kontos
- University of Pittsburgh, Department of Orthopedic Surgery, United States of America
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25
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Kulbe JR, Jain S, Nelson LD, Korley FK, Mukherjee P, Sun X, Okonkwo DO, Giacino JT, Vassar MJ, Robertson CS, McCrea MA, Wang KKW, Temkin N, Mac Donald CL, Taylor SR, Ferguson AR, Markowitz AJ, Diaz-Arrastia R, Manley GT, Stein MB. Association of day-of-injury plasma glial fibrillary acidic protein concentration and six-month posttraumatic stress disorder in patients with mild traumatic brain injury. Neuropsychopharmacology 2022; 47:2300-2308. [PMID: 35717463 PMCID: PMC9630517 DOI: 10.1038/s41386-022-01359-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/16/2022] [Accepted: 05/31/2022] [Indexed: 11/10/2022]
Abstract
Several proteins have proven useful as blood-based biomarkers to assist in evaluation and management of traumatic brain injury (TBI). The objective of this study was to determine whether two day-of-injury blood-based biomarkers are predictive of posttraumatic stress disorder (PTSD). We used data from 1143 individuals with mild TBI (mTBI; defined as admission Glasgow Coma Scale [GCS] score 13-15) enrolled in TRACK-TBI, a prospective longitudinal study of level 1 trauma center patients. Plasma glial fibrillary acidic protein (GFAP) and serum high sensitivity C-reactive protein (hsCRP) were measured from blood collected within 24 h of injury. Two hundred and twenty-seven (19.9% of) patients had probable PTSD (PCL-5 score ≥ 33) at 6 months post-injury. GFAP levels were positively associated (Spearman's rho = 0.35, p < 0.001) with duration of posttraumatic amnesia (PTA). There was an inverse association between PTSD and (log)GFAP (adjusted OR = 0.85, 95% CI 0.77-0.95 per log unit increase) levels, but no significant association with (log)hsCRP (adjusted OR = 1.11, 95% CI 0.98-1.25 per log unit increase) levels. Elevated day-of-injury plasma GFAP, a biomarker of glial reactivity, is associated with reduced risk of PTSD after mTBI. This finding merits replication and additional studies to determine a possible neurocognitive basis for this relationship.
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Affiliation(s)
- Jacqueline R. Kulbe
- grid.266100.30000 0001 2107 4242Department of Psychiatry, University of California, San Diego, La Jolla, CA USA
| | - Sonia Jain
- grid.266100.30000 0001 2107 4242Biostatistics Research Center, Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla, CA USA
| | - Lindsay D. Nelson
- grid.30760.320000 0001 2111 8460Departments of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI USA
| | - Frederick K. Korley
- grid.214458.e0000000086837370Department of Emergency Medicine, University of Michigan, Ann Arbor, MI USA
| | - Pratik Mukherjee
- grid.266102.10000 0001 2297 6811Department of Radiology & Biomedical Imaging, UCSF, San Francisco, CA USA ,grid.266102.10000 0001 2297 6811Department of Bioengineering & Therapeutic Sciences, UCSF, San Francisco, CA USA
| | - Xiaoying Sun
- grid.266100.30000 0001 2107 4242Biostatistics Research Center, Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla, CA USA
| | - David O. Okonkwo
- grid.412689.00000 0001 0650 7433Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - Joseph T. Giacino
- grid.38142.3c000000041936754XDepartment of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA USA ,grid.416228.b0000 0004 0451 8771Spaulding Rehabilitation Hospital, Charlestown, MA USA
| | - Mary J. Vassar
- grid.416732.50000 0001 2348 2960Brain and Spinal Cord Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA USA ,grid.266102.10000 0001 2297 6811Department of Neurological Surgery, UCSF, San Francisco, CA USA
| | - Claudia S. Robertson
- grid.39382.330000 0001 2160 926XDepartment of Neurosurgery, Baylor College of Medicine, Houston, TX USA
| | - Michael A. McCrea
- grid.30760.320000 0001 2111 8460Departments of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI USA
| | - Kevin K. W. Wang
- grid.15276.370000 0004 1936 8091Department of Emergency Medicine, University of Florida, Gainesville, FL USA
| | - Nancy Temkin
- grid.34477.330000000122986657Department of Neurological Surgery, University of Washington, Seattle, WA USA
| | - Christine L. Mac Donald
- grid.34477.330000000122986657Department of Neurological Surgery, University of Washington, Seattle, WA USA
| | - Sabrina R. Taylor
- grid.416732.50000 0001 2348 2960Brain and Spinal Cord Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA USA ,grid.266102.10000 0001 2297 6811Department of Neurological Surgery, UCSF, San Francisco, CA USA
| | - Adam R. Ferguson
- grid.416732.50000 0001 2348 2960Brain and Spinal Cord Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA USA
| | - Amy J. Markowitz
- grid.416732.50000 0001 2348 2960Brain and Spinal Cord Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA USA
| | - Ramon Diaz-Arrastia
- grid.25879.310000 0004 1936 8972Department of Neurology, University of Pennsylvania, Philadelphia, PA USA
| | - Geoffrey T. Manley
- grid.416732.50000 0001 2348 2960Brain and Spinal Cord Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA USA ,grid.266102.10000 0001 2297 6811Department of Neurological Surgery, UCSF, San Francisco, CA USA
| | - Murray B. Stein
- grid.266100.30000 0001 2107 4242Department of Psychiatry, University of California, San Diego, La Jolla, CA USA ,grid.266100.30000 0001 2107 4242School of Public Health, University of California, San Diego, La Jolla, CA USA ,grid.410371.00000 0004 0419 2708VA San Diego Healthcare System, San Diego, CA USA
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26
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Maas AIR, Menon DK, Manley GT, Abrams M, Åkerlund C, Andelic N, Aries M, Bashford T, Bell MJ, Bodien YG, Brett BL, Büki A, Chesnut RM, Citerio G, Clark D, Clasby B, Cooper DJ, Czeiter E, Czosnyka M, Dams-O’Connor K, De Keyser V, Diaz-Arrastia R, Ercole A, van Essen TA, Falvey É, Ferguson AR, Figaji A, Fitzgerald M, Foreman B, Gantner D, Gao G, Giacino J, Gravesteijn B, Guiza F, Gupta D, Gurnell M, Haagsma JA, Hammond FM, Hawryluk G, Hutchinson P, van der Jagt M, Jain S, Jain S, Jiang JY, Kent H, Kolias A, Kompanje EJO, Lecky F, Lingsma HF, Maegele M, Majdan M, Markowitz A, McCrea M, Meyfroidt G, Mikolić A, Mondello S, Mukherjee P, Nelson D, Nelson LD, Newcombe V, Okonkwo D, Orešič M, Peul W, Pisică D, Polinder S, Ponsford J, Puybasset L, Raj R, Robba C, Røe C, Rosand J, Schueler P, Sharp DJ, Smielewski P, Stein MB, von Steinbüchel N, Stewart W, Steyerberg EW, Stocchetti N, Temkin N, Tenovuo O, Theadom A, Thomas I, Espin AT, Turgeon AF, Unterberg A, Van Praag D, van Veen E, Verheyden J, Vyvere TV, Wang KKW, Wiegers EJA, Williams WH, Wilson L, Wisniewski SR, Younsi A, Yue JK, Yuh EL, Zeiler FA, Zeldovich M, Zemek R. Traumatic brain injury: progress and challenges in prevention, clinical care, and research. Lancet Neurol 2022; 21:1004-1060. [PMID: 36183712 PMCID: PMC10427240 DOI: 10.1016/s1474-4422(22)00309-x] [Citation(s) in RCA: 168] [Impact Index Per Article: 84.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 07/22/2022] [Indexed: 02/06/2023]
Abstract
Traumatic brain injury (TBI) has the highest incidence of all common neurological disorders, and poses a substantial public health burden. TBI is increasingly documented not only as an acute condition but also as a chronic disease with long-term consequences, including an increased risk of late-onset neurodegeneration. The first Lancet Neurology Commission on TBI, published in 2017, called for a concerted effort to tackle the global health problem posed by TBI. Since then, funding agencies have supported research both in high-income countries (HICs) and in low-income and middle-income countries (LMICs). In November 2020, the World Health Assembly, the decision-making body of WHO, passed resolution WHA73.10 for global actions on epilepsy and other neurological disorders, and WHO launched the Decade for Action on Road Safety plan in 2021. New knowledge has been generated by large observational studies, including those conducted under the umbrella of the International Traumatic Brain Injury Research (InTBIR) initiative, established as a collaboration of funding agencies in 2011. InTBIR has also provided a huge stimulus to collaborative research in TBI and has facilitated participation of global partners. The return on investment has been high, but many needs of patients with TBI remain unaddressed. This update to the 2017 Commission presents advances and discusses persisting and new challenges in prevention, clinical care, and research. In LMICs, the occurrence of TBI is driven by road traffic incidents, often involving vulnerable road users such as motorcyclists and pedestrians. In HICs, most TBI is caused by falls, particularly in older people (aged ≥65 years), who often have comorbidities. Risk factors such as frailty and alcohol misuse provide opportunities for targeted prevention actions. Little evidence exists to inform treatment of older patients, who have been commonly excluded from past clinical trials—consequently, appropriate evidence is urgently required. Although increasing age is associated with worse outcomes from TBI, age should not dictate limitations in therapy. However, patients injured by low-energy falls (who are mostly older people) are about 50% less likely to receive critical care or emergency interventions, compared with those injured by high-energy mechanisms, such as road traffic incidents. Mild TBI, defined as a Glasgow Coma sum score of 13–15, comprises most of the TBI cases (over 90%) presenting to hospital. Around 50% of adult patients with mild TBI presenting to hospital do not recover to pre-TBI levels of health by 6 months after their injury. Fewer than 10% of patients discharged after presenting to an emergency department for TBI in Europe currently receive follow-up. Structured follow-up after mild TBI should be considered good practice, and urgent research is needed to identify which patients with mild TBI are at risk for incomplete recovery. The selection of patients for CT is an important triage decision in mild TBI since it allows early identification of lesions that can trigger hospital admission or life-saving surgery. Current decision making for deciding on CT is inefficient, with 90–95% of scanned patients showing no intracranial injury but being subjected to radiation risks. InTBIR studies have shown that measurement of blood-based biomarkers adds value to previously proposed clinical decision rules, holding the potential to improve efficiency while reducing radiation exposure. Increased concentrations of biomarkers in the blood of patients with a normal presentation CT scan suggest structural brain damage, which is seen on MR scanning in up to 30% of patients with mild TBI. Advanced MRI, including diffusion tensor imaging and volumetric analyses, can identify additional injuries not detectable by visual inspection of standard clinical MR images. Thus, the absence of CT abnormalities does not exclude structural damage—an observation relevant to litigation procedures, to management of mild TBI, and when CT scans are insufficient to explain the severity of the clinical condition. Although blood-based protein biomarkers have been shown to have important roles in the evaluation of TBI, most available assays are for research use only. To date, there is only one vendor of such assays with regulatory clearance in Europe and the USA with an indication to rule out the need for CT imaging for patients with suspected TBI. Regulatory clearance is provided for a combination of biomarkers, although evidence is accumulating that a single biomarker can perform as well as a combination. Additional biomarkers and more clinical-use platforms are on the horizon, but cross-platform harmonisation of results is needed. Health-care efficiency would benefit from diversity in providers. In the intensive care setting, automated analysis of blood pressure and intracranial pressure with calculation of derived parameters can help individualise management of TBI. Interest in the identification of subgroups of patients who might benefit more from some specific therapeutic approaches than others represents a welcome shift towards precision medicine. Comparative-effectiveness research to identify best practice has delivered on expectations for providing evidence in support of best practices, both in adult and paediatric patients with TBI. Progress has also been made in improving outcome assessment after TBI. Key instruments have been translated into up to 20 languages and linguistically validated, and are now internationally available for clinical and research use. TBI affects multiple domains of functioning, and outcomes are affected by personal characteristics and life-course events, consistent with a multifactorial bio-psycho-socio-ecological model of TBI, as presented in the US National Academies of Sciences, Engineering, and Medicine (NASEM) 2022 report. Multidimensional assessment is desirable and might be best based on measurement of global functional impairment. More work is required to develop and implement recommendations for multidimensional assessment. Prediction of outcome is relevant to patients and their families, and can facilitate the benchmarking of quality of care. InTBIR studies have identified new building blocks (eg, blood biomarkers and quantitative CT analysis) to refine existing prognostic models. Further improvement in prognostication could come from MRI, genetics, and the integration of dynamic changes in patient status after presentation. Neurotrauma researchers traditionally seek translation of their research findings through publications, clinical guidelines, and industry collaborations. However, to effectively impact clinical care and outcome, interactions are also needed with research funders, regulators, and policy makers, and partnership with patient organisations. Such interactions are increasingly taking place, with exemplars including interactions with the All Party Parliamentary Group on Acquired Brain Injury in the UK, the production of the NASEM report in the USA, and interactions with the US Food and Drug Administration. More interactions should be encouraged, and future discussions with regulators should include debates around consent from patients with acute mental incapacity and data sharing. Data sharing is strongly advocated by funding agencies. From January 2023, the US National Institutes of Health will require upload of research data into public repositories, but the EU requires data controllers to safeguard data security and privacy regulation. The tension between open data-sharing and adherence to privacy regulation could be resolved by cross-dataset analyses on federated platforms, with the data remaining at their original safe location. Tools already exist for conventional statistical analyses on federated platforms, however federated machine learning requires further development. Support for further development of federated platforms, and neuroinformatics more generally, should be a priority. This update to the 2017 Commission presents new insights and challenges across a range of topics around TBI: epidemiology and prevention (section 1 ); system of care (section 2 ); clinical management (section 3 ); characterisation of TBI (section 4 ); outcome assessment (section 5 ); prognosis (Section 6 ); and new directions for acquiring and implementing evidence (section 7 ). Table 1 summarises key messages from this Commission and proposes recommendations for the way forward to advance research and clinical management of TBI.
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Affiliation(s)
- Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Mathew Abrams
- International Neuroinformatics Coordinating Facility, Karolinska Institutet, Stockholm, Sweden
| | - Cecilia Åkerlund
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Nada Andelic
- Division of Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Marcel Aries
- Department of Intensive Care, Maastricht UMC, Maastricht, Netherlands
| | - Tom Bashford
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Michael J Bell
- Critical Care Medicine, Neurological Surgery and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Yelena G Bodien
- Department of Neurology and Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
| | - Benjamin L Brett
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - András Büki
- Department of Neurosurgery, Faculty of Medicine and Health Örebro University, Örebro, Sweden
- Department of Neurosurgery, Medical School; ELKH-PTE Clinical Neuroscience MR Research Group; and Neurotrauma Research Group, Janos Szentagothai Research Centre, University of Pecs, Pecs, Hungary
| | - Randall M Chesnut
- Department of Neurological Surgery and Department of Orthopaedics and Sports Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, Universita Milano Bicocca, Milan, Italy
- NeuroIntensive Care, San Gerardo Hospital, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
| | - David Clark
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Betony Clasby
- Department of Sociological Studies, University of Sheffield, Sheffield, UK
| | - D Jamie Cooper
- School of Public Health and Preventive Medicine, Monash University and The Alfred Hospital, Melbourne, VIC, Australia
| | - Endre Czeiter
- Department of Neurosurgery, Medical School; ELKH-PTE Clinical Neuroscience MR Research Group; and Neurotrauma Research Group, Janos Szentagothai Research Centre, University of Pecs, Pecs, Hungary
| | - Marek Czosnyka
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Kristen Dams-O’Connor
- Department of Rehabilitation and Human Performance and Department of Neurology, Brain Injury Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Véronique De Keyser
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Ramon Diaz-Arrastia
- Department of Neurology and Center for Brain Injury and Repair, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Thomas A van Essen
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
- Department of Neurosurgery, Medical Center Haaglanden, The Hague, Netherlands
| | - Éanna Falvey
- College of Medicine and Health, University College Cork, Cork, Ireland
| | - Adam R Ferguson
- Brain and Spinal Injury Center, Department of Neurological Surgery, Weill Institute for Neurosciences, University of California San Francisco and San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA
| | - Anthony Figaji
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Curtin University, Bentley, WA, Australia
- Perron Institute for Neurological and Translational Sciences, Nedlands, WA, Australia
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, University of Cincinnati, Cincinnati, OH, USA
| | - Dashiell Gantner
- School of Public Health and Preventive Medicine, Monash University and The Alfred Hospital, Melbourne, VIC, Australia
| | - Guoyi Gao
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine
| | - Joseph Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School and Spaulding Rehabilitation Hospital, Charlestown, MA, USA
| | - Benjamin Gravesteijn
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Fabian Guiza
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Deepak Gupta
- Department of Neurosurgery, Neurosciences Centre and JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Mark Gurnell
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Juanita A Haagsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Flora M Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
| | - Gregory Hawryluk
- Section of Neurosurgery, GB1, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Peter Hutchinson
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Mathieu van der Jagt
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Sonia Jain
- Biostatistics Research Center, Herbert Wertheim School of Public Health, University of California, San Diego, CA, USA
| | - Swati Jain
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Ji-yao Jiang
- Department of Neurosurgery, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hope Kent
- Department of Psychology, University of Exeter, Exeter, UK
| | - Angelos Kolias
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Erwin J O Kompanje
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Marc Maegele
- Cologne-Merheim Medical Center, Department of Trauma and Orthopedic Surgery, Witten/Herdecke University, Cologne, Germany
| | - Marek Majdan
- Institute for Global Health and Epidemiology, Department of Public Health, Faculty of Health Sciences and Social Work, Trnava University, Trnava, Slovakia
| | - Amy Markowitz
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Michael McCrea
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Ana Mikolić
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Pratik Mukherjee
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - David Nelson
- Section for Anesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Lindsay D Nelson
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Virginia Newcombe
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - David Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matej Orešič
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Wilco Peul
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
| | - Dana Pisică
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jennie Ponsford
- Monash-Epworth Rehabilitation Research Centre, Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, VIC, Australia
| | - Louis Puybasset
- Department of Anesthesiology and Intensive Care, APHP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Chiara Robba
- Department of Anaesthesia and Intensive Care, Policlinico San Martino IRCCS for Oncology and Neuroscience, Genova, Italy, and Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Italy
| | - Cecilie Røe
- Division of Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Jonathan Rosand
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - David J Sharp
- Department of Brain Sciences, Imperial College London, London, UK
| | - Peter Smielewski
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Murray B Stein
- Department of Psychiatry and Department of Family Medicine and Public Health, UCSD School of Medicine, La Jolla, CA, USA
| | - Nicole von Steinbüchel
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Goettingen, Germany
| | - William Stewart
- Department of Neuropathology, Queen Elizabeth University Hospital and University of Glasgow, Glasgow, UK
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences Leiden University Medical Center, Leiden, Netherlands
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, Milan University, and Neuroscience ICU, Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nancy Temkin
- Departments of Neurological Surgery, and Biostatistics, University of Washington, Seattle, WA, USA
| | - Olli Tenovuo
- Department of Rehabilitation and Brain Trauma, Turku University Hospital, and Department of Neurology, University of Turku, Turku, Finland
| | - Alice Theadom
- National Institute for Stroke and Applied Neurosciences, Faculty of Health and Environmental Studies, Auckland University of Technology, Auckland, New Zealand
| | - Ilias Thomas
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Abel Torres Espin
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, CHU de Québec-Université Laval Research Center, Québec City, QC, Canada
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Dominique Van Praag
- Departments of Clinical Psychology and Neurosurgery, Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Ernest van Veen
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | - Thijs Vande Vyvere
- Department of Radiology, Faculty of Medicine and Health Sciences, Department of Rehabilitation Sciences (MOVANT), Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Kevin K W Wang
- Department of Psychiatry, University of Florida, Gainesville, FL, USA
| | - Eveline J A Wiegers
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - W Huw Williams
- Centre for Clinical Neuropsychology Research, Department of Psychology, University of Exeter, Exeter, UK
| | - Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling, UK
| | - Stephen R Wisniewski
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Alexander Younsi
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - John K Yue
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Esther L Yuh
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Frederick A Zeiler
- Departments of Surgery, Human Anatomy and Cell Science, and Biomedical Engineering, Rady Faculty of Health Sciences and Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Marina Zeldovich
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Goettingen, Germany
| | - Roger Zemek
- Departments of Pediatrics and Emergency Medicine, University of Ottawa, Children’s Hospital of Eastern Ontario, ON, Canada
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Guzowski NS, Hoelzle JB, McCrea MA, Nelson LD. Differing associations between measures of somatic symptom reporting, personality, and mild traumatic brain injury (mTBI). Clin Neuropsychol 2022; 36:2135-2152. [PMID: 34615438 PMCID: PMC8986884 DOI: 10.1080/13854046.2021.1985617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 09/22/2021] [Indexed: 01/27/2023]
Abstract
Objective: Somatic complaints are known to complicate recovery after mild traumatic brain injury (mTBI), but the construct is poorly understood due to evolving definitions of associated disorders and uncertainty related to its position within the broader construct network of psychopathology. Methods: To better understand measures of somatic symptom reporting widely used with mTBI patients, we examined relationships between the Brief Symptom Inventory-18 Somatization (SOM) scale, the Minnesota Multiple Personality Inventory-2-Restructured Form Somatic Complaints (RC1) scale, other measures of psychological and personality functioning, and mTBI in both athlete concussion (n = 100) and civilian trauma (n = 75 mTBI, n = 79 orthopedic injury) samples. Results: The association between post-injury SOM and RC1 was moderate (r=.37-.46) and similar to associations between these inventories and depression and anxiety symptoms. In civilians with mTBI, RC1 was more strongly associated with diverse personality dimensions than SOM. mTBI athletes reported increases in somatic symptoms from pre- to post-injury, with larger group effect sizes on SOM (ηp2 = 0.34, p < .001) than RC1 (ηp2 = 0.09, p = .003). Civilian mTBI patients showed a trend for somewhat higher post-injury RC1 scores than orthopedic trauma controls (ηp2 = 0.02, p = .068). Conclusions: Findings add to the current knowledge of the influence of somatic complaints in mTBI. BSI-18 SOM and MMPI-2-RF RC1 are not interchangeable, as they are only modestly correlated and demonstrate differing associations with other clinical outcomes and mTBI.
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Affiliation(s)
| | | | - Michael A. McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee WI
| | - Lindsay D. Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee WI
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Temkin N, Machamer J, Dikmen S, Nelson LD, Barber J, Hwang PH, Boase K, Stein MB, Sun X, Giacino J, McCrea MA, Taylor SR, Jain S, Manley G. Risk Factors for High Symptom Burden Three Months after Traumatic Brain Injury and Implications for Clinical Trial Design: A Transforming Research and Clinical Knowledge in Traumatic Brain Injury Study. J Neurotrauma 2022; 39:1524-1532. [PMID: 35754333 PMCID: PMC9689769 DOI: 10.1089/neu.2022.0113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
More than 75% of patients presenting to level I trauma centers in the United States with suspicion of TBI sufficient to require a clinical computed tomography scan report injury-related symptoms 3 months later. There are currently no approved treatments, and few clinical trials have evaluated possible treatments. Efficient trials will require subject inclusion and exclusion criteria that balance cost-effective recruitment with enrolling individuals with a higher chance of benefiting from the interventions. Using data from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study, we examined the relationship of 3-month symptoms to pre-injury, demographic, and acute characteristics as well as 2-week symptoms and blood-based biomarkers to identify and evaluate factors that may be used for sample enrichment for clinical trials. Many of the risk factors for TBI symptoms reported in the literature were supported, but the effect sizes of each were small or moderate (< 0.5). The only factors with large effect sizes when predicting 3-month symptom burden were TBI-related (i.e., post-concussive) and post-traumatic stress symptom levels at 2 weeks (respective effect sizes 1.13 and 1.34). TBI severity was not significantly associated with 3-month symptom burden (p = 0.37). Using simulated data to evaluate the effect of enrichment, we showed that including only people with high symptom burden at 2 weeks would permit trials to reduce the sample size by half, with minimal increase in screening, as compared with enrolling an unenriched sample. Clinical trials aimed at reducing symptoms after TBI can be efficiently conducted by enriching the included sample with people reporting a high early symptom burden.
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Affiliation(s)
- Nancy Temkin
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Joan Machamer
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Sureyya Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Lindsay D. Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Phillip H. Hwang
- Department of Anatomy and Neurobiology, Boston University, Boston Massachusetts, USA
| | - Kim Boase
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Murray B. Stein
- Department of Psychiatry and Herbert Wertheim School of Public Health, University of California, San Diego, California, USA
| | - Xiaoying Sun
- Biostatistics Research Center Herbert Wertheim School of Public Health, University of California, San Diego, California, USA
| | - Joseph Giacino
- Department of Rehabilitation Medicine, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, Massachusetts, USA
| | - Michael A. McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sabrina R. Taylor
- Brain and Spinal Injury Center, San Francisco California, USA
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Sonia Jain
- Biostatistics Research Center Herbert Wertheim School of Public Health, University of California, San Diego, California, USA
| | - Geoff Manley
- Brain and Spinal Injury Center, San Francisco California, USA
- Department of Neurological Surgery, University of California, San Francisco, California, USA
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Hwang PH, Nelson LD, Sharon JD, McCrea MA, Dikmen SS, Markowitz AJ, Manley GT, Temkin NR. Association Between TBI-Related Hearing Impairment and Cognition: A TRACK-TBI Study. J Head Trauma Rehabil 2022; 37:E327-E335. [PMID: 34698685 PMCID: PMC9035476 DOI: 10.1097/htr.0000000000000735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To examine the association between hearing impairment and cognitive function after traumatic brain injury (TBI). SETTING A total of 18 level I trauma centers throughout the United States in the T ransforming R esearch a nd C linical K nowledge in TBI (TRACK-TBI) study. PARTICIPANTS From February 2014 to June 2018, a total of 2697 participants with TBI were enrolled in TRACK-TBI. Key eligibility criteria included external force trauma to the head, presentation to a participating level I trauma center, and receipt of a clinically indicated head computed tomographic (CT) scan within 24 hours of injury. A total of 1267 participants were evaluated in the study, with 216 participants with hearing impairment and 1051 participants without hearing impairment. Those with missing or unknown hearing status or cognitive assessment were excluded from analysis. DESIGN Prospective, observational cohort study. MAIN MEASURES Hearing impairment at 2 weeks post-TBI was based on self-report. Participants who indicated worse hearing in one or both ears were defined as having hearing impairment, whereas those who denied worse hearing in either ear were defined as not having hearing impairment and served as the reference group. Cognitive outcomes at 6 months post-TBI included executive functioning and processing speed, as measured by the Trail Making Test (TMT) B/A and the Wechsler Adult Intelligence Scale, Fourth Edition, Processing Speed Index subscale (WAIS-IV PSI), respectively. RESULTS TBI-related hearing impairment had a small but significantly greater TMT B/A ratio than without TBI-related hearing impairment: mean difference ( B ) = 0.25; 95% CI, 0.07 to 0.43; P = .005. No significant mean differences on WAIS-IV PSI scores were found between participants with and without TBI-related hearing impairment: B = 0.36; 95% CI, -2.07 to 2.60; P = .825. CONCLUSION We conclude that TBI-related hearing impairment at 6 months postinjury was significantly associated with worse executive functioning but not cognitive processing speed.
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Affiliation(s)
- Phillip H Hwang
- Department of Anatomy & Neurobiology, Boston University, Boston, Massachusetts (Dr Hwang); Departments of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee (Drs Nelson and McCrea); Departments of Otolaryngology (Dr Sharon) and Neurological Surgery (Dr Manley), University of California San Francisco; Departments of Rehabilitation Medicine (Dr Dikmen), Neurological Surgery (Dr Temkin), and Biostatistics (Dr Temkin), University of Washington, Seattle; and Brain and Spinal Cord Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California (Ms Markowitz)
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Korley FK, Jain S, Sun X, Puccio AM, Yue JK, Gardner RC, Wang KKW, Okonkwo DO, Yuh EL, Mukherjee P, Nelson LD, Taylor SR, Markowitz AJ, Diaz-Arrastia R, Manley GT. Prognostic value of day-of-injury plasma GFAP and UCH-L1 concentrations for predicting functional recovery after traumatic brain injury in patients from the US TRACK-TBI cohort: an observational cohort study. Lancet Neurol 2022; 21:803-813. [PMID: 35963263 PMCID: PMC9462598 DOI: 10.1016/s1474-4422(22)00256-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 04/26/2022] [Accepted: 05/30/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND The prognostic value of glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase L1 (UCH-L1) as day-of-injury predictors of functional outcome after traumatic brain injury is not well understood. GFAP is a protein found in glial cells and UCH-L1 is found in neurons, and these biomarkers have been cleared to aid in decision making regarding whether brain CT should be performed after traumatic brain injury. We aimed to quantify their prognostic accuracy and investigate whether these biomarkers contribute novel prognostic information to existing clinical models. METHODS We enrolled patients from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) observational cohort study. TRACK-TBI includes patients 17 years and older who are evaluated for TBI at 18 US level 1 trauma centres. All patients receive head CT at evaluation, have adequate visual acuity and hearing preinjury, and are fluent in either English or Spanish. In our analysis, we included participants aged 17-90 years who had day-of-injury plasma samples for measurement of GFAP and UCH-L1 and completed 6-month assessments for outcome due to traumatic brain injury with the Glasgow Outcome Scale-Extended (GOSE-TBI). Biomarkers were analysed as continuous variables and in quintiles. This study is registered with ClinicalTrials.gov, NCT02119182. FINDINGS We enrolled 2552 patients from Feb 26, 2014, to Aug 8, 2018. Of the 1696 participants with brain injury and data available at baseline and at 6 months who were included in the analysis, 120 (7·1%) died (GOSE-TBI=1), 235 (13·9%) had an unfavourable outcome (ie, GOSE-TBI ≤4), 1135 (66·9%) had incomplete recovery (ie, GOSE-TBI <8), and 561 (33·1%) recovered fully (ie, GOSE-TBI=8). The area under the curve (AUC) of GFAP for predicting death at 6 months in all patients was 0·87 (95% CI 0·83-0·91), for unfavourable outcome was 0·86 (0·83-0·89), and for incomplete recovery was 0·62 (0·59-0·64). The corresponding AUCs for UCH-L1 were 0·89 (95% CI 0·86-0·92) for predicting death, 0·86 (0·84-0·89) for unfavourable outcome, and 0·61 (0·59-0·64) for incomplete recovery at 6 months. AUCs were higher for participants with traumatic brain injury and Glasgow Coma Scale (GCS) score of 3-12 than for those with GCS score of 13-15. Among participants with GCS score of 3-12 (n=353), adding GFAP and UCH-L1 (alone or combined) to each of the three International Mission for Prognosis and Analysis of Clinical Trials in traumatic brain injury models significantly increased their AUCs for predicting death (AUC range 0·90-0·94) and unfavourable outcome (AUC range 0·83-0·89). However, among participants with GCS score of 13-15 (n=1297), adding GFAP and UCH-L1 to the UPFRONT study model modestly increased the AUC for predicting incomplete recovery (AUC range 0·69-0·69, p=0·025). INTERPRETATION In addition to their known diagnostic value, day-of-injury GFAP and UCH-L1 plasma concentrations have good to excellent prognostic value for predicting death and unfavourable outcome, but not for predicting incomplete recovery at 6 months. These biomarkers contribute the most prognostic information for participants presenting with a GCS score of 3-12. FUNDING US National Institutes of Health, National Institute of Neurologic Disorders and Stroke, US Department of Defense, One Mind, US Army Medical Research and Development Command.
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Affiliation(s)
- Frederick K Korley
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Sonia Jain
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California at San Diego, La Jolla, CA, USA
| | - Xiaoying Sun
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California at San Diego, La Jolla, CA, USA
| | - Ava M Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - John K Yue
- Department of Neurological Surgery, University of California at San Francisco, San Francisco, CA, USA
| | - Raquel C Gardner
- Department of Neurology, Memory and Aging Center, University of California at San Francisco, San Francisco, CA, USA; Weill Institute for Neurosciences, University of California at San Francisco, San Francisco, CA, USA
| | - Kevin K W Wang
- Program for Neurotrauma, Neuroproteomics and Biomarkers Research, Department of Emergency Medicine, McKnight Brain Institute, University of Florida, Gainesville, FL, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Esther L Yuh
- Department of Radiology, University of California at San Francisco, San Francisco, CA, USA
| | - Pratik Mukherjee
- Department of Radiology, University of California at San Francisco, San Francisco, CA, USA
| | - Lindsay D Nelson
- Department of Neurosurgery and Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sabrina R Taylor
- Brain and Spinal Injury Center, University of California at San Francisco, San Francisco, CA, USA
| | - Amy J Markowitz
- Department of Neurological Surgery, University of California at San Francisco, San Francisco, CA, USA
| | - Ramon Diaz-Arrastia
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA; Traumatic Brain Injury Clinical Research Center, Penn Presbyterian Medical Center, Philadelphia, PA, USA
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California at San Francisco, San Francisco, CA, USA
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Vorn R, Mithani S, Devoto C, Meier TB, Lai C, Yun S, Broglio SP, McAllister TW, Giza CC, Kim HS, Huber D, Harezlak J, Cameron KL, McGinty G, Jackson J, Guskiewicz KM, Mihalik JP, Brooks A, Duma S, Rowson S, Nelson LD, Pasquina P, McCrea MA, Gill JM. Proteomic Profiling of Plasma Biomarkers Associated With Return to Sport Following Concussion: Findings From the NCAA and Department of Defense CARE Consortium. Front Neurol 2022; 13:901238. [PMID: 35928129 PMCID: PMC9343581 DOI: 10.3389/fneur.2022.901238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 06/08/2022] [Indexed: 11/30/2022] Open
Abstract
Objective To investigate the plasma proteomic profiling in identifying biomarkers related to return to sport (RTS) following a sport-related concussion (SRC). Methods This multicenter, prospective, case-control study was part of a larger cohort study conducted by the NCAA-DoD Concussion Assessment, Research, and Education (CARE) Consortium, athletes (n = 140) with blood collected within 48 h of injury and reported day to asymptomatic were included in this study, divided into two groups: (1) recovery <14-days (n = 99) and (2) recovery ≥14-days (n = 41). We applied a highly multiplexed proteomic technique that uses DNA aptamers assay to target 1,305 proteins in plasma samples from concussed athletes with <14-days and ≥14-days. Results We identified 87 plasma proteins significantly dysregulated (32 upregulated and 55 downregulated) in concussed athletes with recovery ≥14-days relative to recovery <14-days groups. The significantly dysregulated proteins were uploaded to Ingenuity Pathway Analysis (IPA) software for analysis. Pathway analysis showed that significantly dysregulated proteins were associated with STAT3 pathway, regulation of the epithelial mesenchymal transition by growth factors pathway, and acute phase response signaling. Conclusion Our data showed the feasibility of large-scale plasma proteomic profiling in concussed athletes with a <14-days and ≥ 14-days recovery. These findings provide a possible understanding of the pathophysiological mechanism in neurobiological recovery. Further study is required to determine whether these proteins can aid clinicians in RTS decisions.
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Affiliation(s)
- Rany Vorn
- School of Nursing, Johns Hopkins University, Baltimore, MD, United States
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, United States
| | - Sara Mithani
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, United States
- School of Nursing, University of Texas Health Science Center San Antonio, San Antonio, TX, United States
| | - Christina Devoto
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, United States
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States
| | - Timothy B. Meier
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Chen Lai
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, United States
- Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Sijung Yun
- Predictiv Care, Mountain View, CA, United States
| | - Steven P. Broglio
- Michigan Concussion Center, University of Michigan, Ann Arbor, MI, United States
| | - Thomas W. McAllister
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Christopher C. Giza
- Departments of Pediatrics and Neurosurgery, University of California, Los Angeles, Los Angeles, CA, United States
- UCLA Steve Tisch BrainSPORT Program, University of California, Los Angeles, Los Angeles, CA, United States
| | - Hyung-Suk Kim
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, United States
| | - Daniel Huber
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Jaroslaw Harezlak
- Department of Epidemiology and Biostatistics School of Public Health-Bloomington, Indiana University, Bloomington, IN, United States
| | - Kenneth L. Cameron
- John A. Feagin Sports Medicine Fellowship, Keller Army Hospital, West Point, NY, United States
| | - Gerald McGinty
- United States Air Force Academy, Colorado Springs, CO, United States
| | - Jonathan Jackson
- United States Air Force Academy, Colorado Springs, CO, United States
| | - Kevin M. Guskiewicz
- Matthew Gfeller Center, Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Jason P. Mihalik
- Matthew Gfeller Center, Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Alison Brooks
- Department of Orthopedics, Division of Sports Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Stefan Duma
- Department of Biomedical Engineering and Mechanics, Virginia Tech, Blacksburg, VA, United States
| | - Steven Rowson
- Department of Biomedical Engineering and Mechanics, Virginia Tech, Blacksburg, VA, United States
| | - Lindsay D. Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Paul Pasquina
- Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Michael A. McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Jessica M. Gill
- School of Nursing, Johns Hopkins University, Baltimore, MD, United States
- Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
- Department of Neurology, Johns Hopkins University, Baltimore, MD, United States
- *Correspondence: Jessica M. Gill
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Brett BL, Nelson LD, Meier TB. The Association Between Concussion History and Increased Symptom Severity Reporting Is Independent of Common Medical Comorbidities, Personality Factors, and Sleep Quality in Collegiate Athletes. J Head Trauma Rehabil 2022; 37:E258-E267. [PMID: 34570026 PMCID: PMC8940748 DOI: 10.1097/htr.0000000000000724] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE We investigated the degree to which the association between history of concussion with psychological distress and general symptom severity is independent of several factors commonly associated with elevated symptom severity. We also examined whether symptom severity endorsement was associated with concussion injury specifically or response to injury in general. SETTING Academic medical center. PARTICIPANTS Collegiate athletes ( N = 106; age: M = 21.37 ± 1.69 years; 33 female) were enrolled on the basis of strict medical/psychiatric exclusion criteria. DESIGN Cross-sectional single-visit study. Comprehensive assessment, including semistructured interviews to retrospectively diagnose the number of previous concussions, was completed. Single-predictor and stepwise regression models were fit to examine the predictive value of prior concussion and orthopedic injuries on symptom severity, both individually and controlling for confounding factors. MAIN OUTCOME MEASURES Psychological distress was operationalized as Brief Symptom Inventory-18 Global Severity Index (BSI-GSI) ratings; concussion-related symptom severity was measured using the Sport Concussion Assessment Tool. RESULTS Controlling for baseline factors associated with the symptom outcomes (agreeableness, neuroticism, negative emotionality, and sleep quality), concussion history was significantly associated with psychological distress ( B = 1.25 [0.55]; P = .025, Δ R2 = 0.034) and concussion-like symptom severity ( B = 0.22 [0.08]; P = .005, Δ R2 = 0.064) and accounted for a statistically significant amount of unique variance in symptom outcomes. Orthopedic injury history was not individually predictive of psychological distress ( B = -0.06 [0.53]; P = .905) or general symptom severity ( B = 0.06 [0.08]; P = .427) and did not explain the relationship between concussion history and symptom outcomes. CONCLUSIONS Concussion history is associated with subtle elevations in symptom severity in collegiate-aged athletes; this relationship is independent of medical, lifestyle (ie, sleep), and personality factors. Furthermore, this relationship is associated with brain injury (ie, concussion) and is not a general response to injury history.
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Affiliation(s)
- Benjamin L Brett
- Departments of Neurosurgery and Neurology (Drs Brett and Nelson) and Neurosurgery, Biomedical Engineering, and Cell Biology, Neurobiology, and Anatomy (Dr Meier), Medical College of Wisconsin, Milwaukee
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Magnus BE, Balsis S, Giacino JT, McCrea MA, Temkin NR, Whyte J, Manley GT, Nelson LD. Improving the Precision of the Glasgow Outcome Scale-Extended Using Item Response Theory: A TRACK-TBI Study. J Neurotrauma 2022; 39:870-878. [PMID: 35317604 PMCID: PMC9225413 DOI: 10.1089/neu.2021.0421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
The Glasgow Outcome Scale-Extended (GOSE) is a functional outcome measure intended to place individuals with traumatic brain injury (TBI) into one of eight broad levels of injury-related disability. This simplicity is not always optimal, particularly when more granular assessment of individuals' injury recovery is desired. The GOSE, however, is customarily assessed using a multi-question interview that contains richer information than is reflected in the GOSE score. Using data from the multi-center Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study (N = 1544), we used item response theory (IRT) to evaluate whether rescoring the GOSE using IRT, which posits that a continuous latent variable (disability) underlies responses, can yield a more precise index of injury-related functional limitations. We fit IRT models to GOSE interview responses collected at three months post-injury. Each participant's level of functional limitation was estimated from the model (GOSE-IRT) and comparisons were made between IRT-based and standard (GOSE-Ordinal) scores. The IRT scoring resulted in 141 possible scores (vs. 7 GOSE-Ordinal scores in this sample of individuals with GOSE scores ranging between 2 and 8). Moreover, GOSE-IRT scores were significantly more strongly associated with measures of TBI-related symptoms, psychological symptoms, and quality of life. Our findings demonstrate that rescoring the GOSE interview using IRT yields more granular, meaningful measurement of injury-related functional limitations, while adding no additional respondent or examiner burden. This technique may have utility for many applications, such as clinical trials aiming to detect small treatment effects, and small-scale studies that need to maximize statistical efficiency.
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Affiliation(s)
- Brooke E. Magnus
- Department of Psychology and Neuroscience, Boston College, Chestnut Hill, Massachusetts, USA.,Address correspondence to: Brooke E. Magnus, PhD, Department of Psychology and Neuroscience, Boston College, McGuinn 300, 140 Commonwealth Avenue, Chestnut Hill, Massachusetts, 02467, USA
| | - Steve Balsis
- Department of Psychology, University of Massachusetts Lowell, Lowell, Massachusetts, USA
| | - Joseph T. Giacino
- Harvard Medical School and Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
| | - Michael A. McCrea
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - John Whyte
- Moss Rehabilitation Research Institute, Elkins Park, Pennsylvania, USA
| | | | - Lindsay D. Nelson
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Morris RS, Figueroa JF, Pokrzywa CJ, Barber JK, Temkin NR, Bergner C, Karam BS, Murphy P, Nelson LD, Laud P, Cooper Z, de Moya M, Trevino C, Tignanelli CJ, deRoon-Cassini TA. Predicting outcomes after traumatic brain injury: A novel hospital prediction model for a patient reported outcome. Am J Surg 2022; 224:1150-1155. [DOI: 10.1016/j.amjsurg.2022.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 04/14/2022] [Accepted: 05/17/2022] [Indexed: 11/28/2022]
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Abstract
OBJECTIVES The aims of the study were (1) to determine the frequency of neck pain in patients diagnosed with mild traumatic brain injury (mTBI) or concussion in a pediatric level 1 trauma center emergency department (ED), (2) to identify variables associated with neck pain in this population, and (3) to report on aspects of care received in the ED including imaging and medication use. METHODS This is a retrospective chart review of 652 patients presenting to a pediatric ED with diagnosis of concussion/mTBI. Charts were reviewed for the following information: baseline demographic information, mechanism of injury, cause of mTBI, presence or absence of neck pain, point tenderness in the neck on physical examination, and whether the patient followed up within our health system in the 6 months after injury. Charts were also reviewed for other concussion-related symptoms, medication given in the ED, imaging performed in the ED, cervical spine clearance in the ED, and referrals made. For those patients who did have follow-up appointments within our system, additional chart review was performed to determine whether they sought follow-up treatment for symptoms related to concussion/neck pain and the duration of follow-up. Statistical analyses focused on the prevalence of neck pain in the sample. We subsequently explored the degree to which neck pain was associated with other collected variables. RESULTS Of 652 patients, 90 (13.8%) reported neck pain. Acceleration/deceleration injury and motor vehicle accident were predictive of neck pain. Neck pain was less common in those reporting nausea and vomiting. Direct impact of the head against an object was associated with reduced odds of neck pain, but after adjusting for other variables, this was no longer statistically significant. Patients with neck pain were older than those without neck pain. Patients with neck pain were more likely to receive ibuprofen or morphine and undergo imaging of the spine. They were also more likely to receive a referral and follow-up with neurosurgery. There was no significant difference between groups with respect to concussion-related follow-up visits or follow-up visits to a dedicated concussion clinic. CONCLUSIONS Neck pain is a common symptom in pediatric patients with mTBI, although it was more likely in older patients and those presenting with acceleration/deceleration mechanisms. Although patients with neck pain were more likely to receive a referral and follow-up with neurosurgery, they were not more likely to have concussion-related follow-up visits. Indeed, most patients had no follow-up visits related to their concussion, which supports the notion that concussion is a self-limiting condition.
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Affiliation(s)
| | | | | | - Mark Nimmer
- Division of Emergency Medicine, Department of Pediatrics
| | | | - Aniko Szabo
- Division of Biostatistics, Department of Health and Equity, Medical College of Wisconsin, Milwaukee, WI
| | - Huaying Dong
- Division of Emergency Medicine, Department of Pediatrics
| | - Danny Thomas
- Division of Emergency Medicine, Department of Pediatrics
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Nelson LD, Magnus BE, Temkin NR, Dikmen S, Manley GT, Balsis S. How Do Scores on the Functional Status Examination (FSE) Correspond to Scores on the Glasgow Outcome Scale-Extended (GOSE)? Neurotrauma Rep 2022; 3:122-128. [PMID: 35403101 PMCID: PMC8985527 DOI: 10.1089/neur.2021.0057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
This study was designed to determine how raw scores correspond between two alternative measures of functional recovery from traumatic brain injury (TBI), the Functional Status Examination (FSE) and the Glasgow Outcome Scale-Extended (GOSE). Using data from 357 persons with moderate-severe TBI who participated in a large clinical trial, we performed item response theory analysis to characterize the relationship between functional ability measured by the FSE and GOSE at 6 months post-injury. Results revealed that raw scores for the FSE and GOSE can be linked, and a table is provided to translate scores from one instrument to the other. For example, a FSE score of 7 (on its 0-21 scale, where higher scores reflect more impairment) is equivalent to a GOSE score of 6 (where GOSE is scaled on an 8-point scale, with higher scores reflecting less impairment). These results allow clinicians or researchers who have a score for a person on one instrument to cross-reference it to a score on the other instrument. Importantly, this enables researchers to combine data sets where some persons only completed the GOSE and some only the FSE. In addition, an investigator could save participant time by eliminating one instrument from a battery of tests, yet still retain a score on that instrument for each participant. More broadly, the findings help anchor scores from these two instruments to the broader continuum of injury-related functional limitations.
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Affiliation(s)
- Lindsay D. Nelson
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,*Address correspondence to: Lindsay D. Nelson, PhD, Departments of Neurosurgery and Neurology, Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI 53226, USA;
| | - Brooke E. Magnus
- Department of Psychology and Neuroscience, Boston College, Chestnut Hill, Massachusetts, USA
| | - Nancy R. Temkin
- Department of Neurological Surgery and Biostatistics, University of Washington, Seattle, Washington, USA
| | - Sureyya Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Geoffrey T. Manley
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Steve Balsis
- Department of Psychology, University of Massachusetts Lowell, Lowell, Massachusetts, USA
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Kaplan AD, Cheng Q, Mohan KA, Nelson LD, Jain S, Levin H, Torres-Espin A, Chou A, Huie JR, Ferguson AR, McCrea M, Giacino J, Sundaram S, Markowitz AJ, Manley GT. Mixture Model Framework for Traumatic Brain Injury Prognosis Using Heterogeneous Clinical and Outcome Data. IEEE J Biomed Health Inform 2022; 26:1285-1296. [PMID: 34310331 PMCID: PMC8789941 DOI: 10.1109/jbhi.2021.3099745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Prognoses of Traumatic Brain Injury (TBI) outcomes are neither easily nor accurately determined from clinical indicators. This is due in part to the heterogeneity of damage inflicted to the brain, ultimately resulting in diverse and complex outcomes. Using a data-driven approach on many distinct data elements may be necessary to describe this large set of outcomes and thereby robustly depict the nuanced differences among TBI patients' recovery. In this work, we develop a method for modeling large heterogeneous data types relevant to TBI. Our approach is geared toward the probabilistic representation of mixed continuous and discrete variables with missing values. The model is trained on a dataset encompassing a variety of data types, including demographics, blood-based biomarkers, and imaging findings. In addition, it includes a set of clinical outcome assessments at 3, 6, and 12 months post-injury. The model is used to stratify patients into distinct groups in an unsupervised learning setting. We use the model to infer outcomes using input data, and show that the collection of input data reduces uncertainty of outcomes over a baseline approach. In addition, we quantify the performance of a likelihood scoring technique that can be used to self-evaluate the extrapolation risk of prognosis on unseen patients.
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Affiliation(s)
- Alan D. Kaplan
- Lawrence Livermore National Laboratory, Livermore, CA, USA
| | - Qi Cheng
- Lawrence Livermore National Laboratory, Livermore, CA, USA
| | | | | | - Sonia Jain
- University of California, San Diego, La Jolla, CA, USA
| | | | | | - Austin Chou
- University of California, San Francisco, CA, USA
| | | | | | - Michael McCrea
- Medical College of Wisconsin, Milwaukee, Wisconsin, WI, USA
| | - Joseph Giacino
- Massachusetts General Hospital, Spaulding Rehabilitation Hospital and Harvard Medical School, Boston, MA, USA
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Abstract
Traumatic brain injury (TBI) is associated with a host of psychiatric and neurobehavioral problems. As mortality rates have declined for severe TBI, attention has turned to the cognitive, affective, and behavioral sequelae of injuries across the severity spectrum, which are often more disabling than residual physical effects. Moderate and severe TBI can cause personality changes including impulsivity, severe irritability, affective instability, and apathy. Mild TBI, once considered a largely benign phenomenon, is now known to be associated with a range of affective symptoms, with suicidality, and with worsening or new onset of several psychiatric disorders including posttraumatic stress disorder and major depressive disorder. Repetitive head impacts, often in athletic contexts, are now believed to be associated with a number of emotional and behavioral sequelae. The nature and etiology of mental health manifestations of TBI (including a combination of brain dysfunction and psychological trauma and interrelationships between cognitive, affective, and physical symptoms) are complex and have been a focus of recent epidemiological and mechanistic studies. This paper will review the epidemiology of psychiatric and neurobehavioral problems after TBI in military, civilian, and athletic contexts.
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Affiliation(s)
- Jonathon R Howlett
- VA San Diego Healthcare System, San Diego, La Jolla, California; Department of Psychiatry, University of California San Diego, La Jolla, California.
| | - Lindsay D Nelson
- Department of Neurosurgery & Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Murray B Stein
- VA San Diego Healthcare System, San Diego, La Jolla, California; Department of Psychiatry, University of California San Diego, La Jolla, California; School of Public Health, University of California San Diego, La Jolla, California
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Nelson LD, Stein MB. Mind the Gap: Missing Links in the Understanding of Traumatic Brain Injury and Mental Health. Biol Psychiatry 2022; 91:400-401. [PMID: 35115093 PMCID: PMC8862512 DOI: 10.1016/j.biopsych.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 12/01/2021] [Indexed: 11/02/2022]
Affiliation(s)
- Lindsay D. Nelson
- Departments of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI USA
| | - Murray B. Stein
- Department of Psychiatry and School of Public Health, University of California San Diego, La Jolla, CA, USA; VA San Diego Healthcare System, San Diego, CA, USA
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Machamer J, Temkin N, Dikmen S, Nelson LD, Barber J, Hwang P, Boase K, Stein MB, Sun X, Giacino J, McCrea MA, Taylor SR, Jain S, Manley G. Symptom Frequency and Persistence in the First Year after Traumatic Brain Injury: A TRACK-TBI Study. J Neurotrauma 2022; 39:358-370. [PMID: 35078327 PMCID: PMC8892966 DOI: 10.1089/neu.2021.0348] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Symptom endorsement after traumatic brain injury (TBI) is common acutely post-injury and is associated with other adverse outcomes. Prevalence of persistent symptoms has been debated, especially in mild TBI (mTBI). A cohort of participants ≥17 years with TBI (n = 2039), 257 orthopedic trauma controls (OTCs), and 300 friend controls (FCs) were enrolled in the TRACK-TBI study and evaluated at 2 weeks and 3, 6, and 12 months post-injury using the Rivermead Post-Concussion Symptoms Questionnaire (RPQ). TBI participants had significantly higher symptom burden than OTCs or FCs at all times, with average scores more than double. TBI cases showed significant decreases in RPQ score between each evaluation (p < 0.001), decreasing ∼1.7 points per month between 2 weeks and 3 months and 0.2 points per month after that. More than 50% of the TBI sample, including >50% of each of the mild and moderate/severe TBI subsamples, continued to endorse three or more symptoms as worse than pre-injury through 12 months post-injury. A majority of TBI participants who endorsed a symptom at 3 months or later did so at the next evaluation as well. Contrary to reviews that report symptom resolution by 3 months post-injury among those with mTBI, this study of participants treated at level 1 trauma centers and having a computed tomography ordered found that persistent symptoms are common to at least a year after TBI. Additionally, although symptom endorsement was not specific to TBI given that they were also reported by OTC and FC participants, TBI participants endorsed over twice the symptom burden compared with the other groups.
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Affiliation(s)
- Joan Machamer
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Nancy Temkin
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA.,Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Sureyya Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Lindsay D Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Phillip Hwang
- Department of Anatomy and Neurobiology, Boston University, Boston, Massachusetts, USA
| | - Kim Boase
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Murray B Stein
- Department of Psychiatry and Herbert Wertheim School of Public Health, Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, California, USA
| | - Xiaoying Sun
- Biostatistics Research Center, Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, California, USA
| | - Joseph Giacino
- Department of Rehabilitation Medicine, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, Massachusetts, USA
| | - Michael A McCrea
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sabrina R Taylor
- Brain and Spinal Injury Center, San Francisco, California, USA.,Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Sonia Jain
- Biostatistics Research Center, Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, California, USA
| | - Geoff Manley
- Brain and Spinal Injury Center, San Francisco, California, USA.,Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
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Wickwire EM, Albrecht JS, Capaldi VF, Jain SO, Gardner RC, Werner JK, Mukherjee P, McKeon AB, Smith MT, Giacino JT, Nelson LD, Williams SG, Collen J, Sun X, Schnyer DM, Markowitz AJ, Manley GT, Krystal AD. Trajectories of Insomnia in Adults After Traumatic Brain Injury. JAMA Netw Open 2022; 5:e2145310. [PMID: 35080600 PMCID: PMC8792888 DOI: 10.1001/jamanetworkopen.2021.45310] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
IMPORTANCE Insomnia is common after traumatic brain injury (TBI) and contributes to morbidity and long-term sequelae. OBJECTIVE To identify unique trajectories of insomnia in the 12 months after TBI. DESIGN, SETTING, AND PARTICIPANTS In this prospective cohort study, latent class mixed models (LCMMs) were used to model insomnia trajectories over time and to classify participants into distinct profile groups. Data from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study, a longitudinal, multisite, observational study, were uploaded to the Federal Interagency Traumatic Brain Injury Repository (FITBIR) database. Participants were enrolled at 1 of 18 participating level I trauma centers and enrolled within 24 hours of TBI injury. Additional data were obtained directly from the TRACK-TBI investigators that will be uploaded to FITBIR in the future. Data were collected from February 26, 2014, to August 8, 2018, and analyzed from July 1, 2020, to November 15, 2021. EXPOSURES Traumatic brain injury. MAIN OUTCOMES AND MEASURES Insomnia Severity Index assessed serially at 2 weeks and 3, 6, and 12 months thereafter. RESULTS The final sample included 2022 participants (1377 [68.1%] men; mean [SD] age, 40.1 [17.2] years) from the FITBIR database and the TRACK-TBI study. The data were best fit by a 5-class LCMM. Of these participants, 1245 (61.6%) reported persistent mild insomnia symptoms (class 1); 627 (31.0%) initially reported mild insomnia symptoms that resolved over time (class 2); 91 (4.5%) reported persistent severe insomnia symptoms (class 3); 44 (2.2%) initially reported severe insomnia symptoms that resolved by 12 months (class 4); and 15 (0.7%) initially reported no insomnia symptoms but had severe symptoms by 12 months (class 5). In a multinomial logistic regression model, several factors significantly associated with insomnia trajectory class membership were identified, including female sex (odds ratio [OR], 1.65 [95% CI, 1.02-2.66]), Black race (OR, 2.36 [95% CI, 1.39-4.01]), history of psychiatric illness (OR, 2.21 [95% CI, 1.35-3.60]), and findings consistent with intracranial injury on computed tomography (OR, 0.36 [95% CI, 0.20-0.65]) when comparing class 3 with class 1. CONCLUSIONS AND RELEVANCE These results suggest important heterogeneity in the course of insomnia after TBI in adults. More work is needed to identify outcomes associated with these insomnia trajectory class subgroups and to identify optimal subgroup-specific treatment approaches.
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Affiliation(s)
- Emerson M. Wickwire
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore
- Sleep Disorders Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore
| | - Jennifer S. Albrecht
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Vincent F. Capaldi
- Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Sonia O. Jain
- Biostatistics Research Center, Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego
| | | | - J. Kent Werner
- Department of Neurology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
- Department of Neurology, The Johns Hopkins University, Baltimore, Maryland
| | - Pratik Mukherjee
- Department of Radiology, School of Medicine, University of California, San Francisco
| | - Ashlee B. McKeon
- Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland
| | - Michael T. Smith
- Division of Behavioral Medicine, Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joseph T. Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts
| | - Lindsay D. Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
- Department of Neurology, Medical College of Wisconsin, Milwaukee
| | - Scott G. Williams
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
- Department of Medicine, Fort Belvoir Community Hospital, Fort Belvoir, Virginia
- Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Jacob Collen
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
- Sleep Disorders Center, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Xiaoying Sun
- Biostatistics Research Center, Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego
| | | | - Amy J. Markowitz
- Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco
| | - Geoffrey T. Manley
- Brain and Spinal Injury Center, University of California, San Francisco
- Department of Neurosurgery, University of California, San Francisco
| | - Andrew D. Krystal
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco
- Weill Institute for Neurosciences, University of California, San Francisco
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Kerschner AE, Huber DL, Brett BL, Meier TB, Nelson LD, McCrea MA. Age-Group Differences and Annual Variation in Return-To-Play Practices After Sport-Related Concussion. Clin J Sport Med 2022; 32:e52-e60. [PMID: 32941381 PMCID: PMC7956921 DOI: 10.1097/jsm.0000000000000871] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 05/30/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To examine return-to-play (RTP) practice differences between high school and collegiate athletes, as well as the stability (ie, year-by-year) in these practices over a 5-year period. We hypothesized that similar protocols for treatment will be comparable across competition levels and that these practices will vary year-to-year. DESIGN Prospective cohort study. SETTING Nine high schools and 4 National Collegiate Athletic Association Division III colleges in Southeastern Wisconsin. PARTICIPANTS AND INDEPENDENT VARIABLES Two-hundred seventy-three (N = 273) athletes with sport-related concussions (SRCs). Independent predictors included competition level (high school, n = 88 vs collegiate, n = 185) and year-of-injury. OUTCOME MEASURES Athletes were evaluated prospectively for differences in symptom duration, symptom free waiting period (SFWP), and time to RTP, as well as longitudinal changes in management. RESULTS High school and collegiate athletes experienced comparable median symptom duration (high school, 6.0 days, interquartile range (IQR) = 3.5-11.0; college, 6.0 days, IQR = 4.0-9.0, P = 0.95), SFWP (high school, 5.0 days, IQR = 3.0-8.0; college, 5.0 days, IQR = 3.0-7.0, P = 0.12), and total time to RTP (high school, 10.5 days, IQR = 7.0-16.0; college, 11.0 days, IQR = 8.0-14.0 days, P = 0.94). A Cox regression analysis revealed a nonsignificant trend toward longer SFWPs in high school athletes (P = 0.055; hazard ratio = 1.347, confidence interval = 0.99-1.83). Among football players, SFWPs in 2017 (Median = 3.5 days, IQR = 1.5-5.0 days) were significantly longer than those in 2014 (Median = 5.0 days, IQR = 4.0-8.5 days, P = 0.029) after correction for multiple comparisons. CONCLUSION Similar postinjury and RTP management practices were observed at the high school and collegiate levels after SRCs. Symptom duration and time from injury to unrestricted RTP were comparable, although high school athletes may have longer SFWPs.
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Affiliation(s)
- Anna E Kerschner
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin; and
| | - Daniel L Huber
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin; and
| | - Benjamin L Brett
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin; and
- Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Timothy B Meier
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin; and
| | - Lindsay D Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin; and
- Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael A McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin; and
- Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin
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Nelson LD, Magnus BE, Temkin NR, Dikmen S, Balsis S. Functional Status Examination Yields Higher Measurement Precision than the Glasgow Outcome Scale-Extended after Moderate-to-Severe Traumatic Brain Injury. J Neurotrauma 2021; 38:3288-3294. [PMID: 34114492 PMCID: PMC8820283 DOI: 10.1089/neu.2021.0152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A limited evidence base supports the Functional Status Examination (FSE) as superior to the more commonly used Glasgow Outcome Scale-Extended (GOSE) for precisely characterizing injury-related functional limitations. The aim of this study was to use modern psychometric tools to test the hypothesis that the FSE is more precise than the GOSE in characterizing individual differences in functional limitations after moderate-to-severe traumatic brain injury (TBI). Secondarily, we sought to confirm that the type of interviewee (patient, significant other) does not affect the test performance of the FSE. Using data from 357 individuals with TBI who participated in the Magnesium Sulfate clinical trial and had six-month outcome data, we performed item response theory (IRT) analyses comparing the FSE and GOSE at six months post-injury. Results showed that the FSE yielded higher measurement precision (IRT test information) than the GOSE across most of the disability severity spectrum. The GOSE yielded more information than the FSE at a very high level of disability, because of the GOSE's assignment of a unique score for individuals who are in a vegetative state. Finally, the FSE showed no evidence of differential item functioning by interviewee, indicating it is appropriate to interview either persons with TBI or significant others and combine data across respondents as is typically done. The findings support the FSE as a viable and oftentimes advantageous substitute for the GOSE in clinical trials and translational studies of TBI.
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Affiliation(s)
- Lindsay D. Nelson
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Brooke E. Magnus
- Department of Psychology and Neuroscience, Boston College, Chestnut Hill, Massachusetts, USA
| | - Nancy R. Temkin
- Department of Neurological Surgery, Department of Biostatistics, and University of Washington, Seattle, Washington, USA
| | - Sureyya Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Steve Balsis
- Department of Psychology, University of Massachusetts Lowell, Lowell, Massachusetts, USA
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Kreitzer N, Jain S, Young JS, Sun X, Stein MB, McCrea MA, Levin HS, Giacino JT, Markowitz AJ, Manley GT, Nelson LD. Comparing the Quality of Life after Brain Injury-Overall Scale and Satisfaction with Life Scale as Outcome Measures for Traumatic Brain Injury Research. J Neurotrauma 2021; 38:3352-3363. [PMID: 34435894 DOI: 10.1089/neu.2020.7546] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
It is important to measure quality of life (QoL) after traumatic brain injury (TBI), yet limited studies have compared QoL inventories. In 2579 TBI patients, orthopedic trauma controls, and healthy friend control participants, we compared the Quality of Life After Brain Injury-Overall Scale (QOLIBRI-OS), developed for TBI patients, to the Satisfaction with Life Scale (SWLS), an index of generic life satisfaction. We tested the hypothesis that group differences (TBI and orthopedic trauma vs. healthy friend controls) would be larger for the QOLIBRI-OS than the SWLS and that the QOLIBRI-OS would manifest more substantial changes over time in the injured groups, demonstrating more relevance of the QOLIBRI-OS to traumatic injury recovery. (1) We compared the group differences (TBI vs. orthopedic trauma control vs. friend control) in QoL as indexed by the SWLS versus the QOLIBRI-OS and (2) characterized changes across time in these two inventories across 1 year in these three groups. Our secondary objective was to characterize the relationship between TBI severity and QoL. As compared with healthy friend controls, the QOLIBRI reflected greater reductions in QoL than the SWLS for both the TBI group (all time points) and the orthopedic trauma control group (2 weeks and 3 months). The QOLIBRI-OS better captured expected improvements in QoL during the injury recovery course in injured groups than the SWLS, which demonstrated smaller changes over time. TBI severity was not consistently or robustly associated with self-reported QoL. The findings imply that, as compared with the SWLS, the QOLIBRI-OS appears to identify QoL issues more specifically relevant to traumatically injured patients and may be a more appropriate primary QoL outcome measure for research focused on the sequelae of traumatic injuries.
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Affiliation(s)
- Natalie Kreitzer
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Sonia Jain
- Biostatistics Research Center, Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla, California, USA
| | - Jacob S Young
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Xiaoying Sun
- Biostatistics Research Center, Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla, California, USA
| | - Murray B Stein
- Departments of Psychiatry and Family Medicine & Public Health, University of California, San Diego, San Diego, California, USA
| | - Michael A McCrea
- Departments of Neurosurgery & Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Harvey S Levin
- Department of Physical Medicine and Rehabilitation, Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School and Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
| | - Amy J Markowitz
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Lindsay D Nelson
- Departments of Neurosurgery & Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Spellecy R, Nelson LD. How Should Investigators Advertise on Social Media for Research Opportunities? Am J Bioeth 2021; 21:42-43. [PMID: 34554066 DOI: 10.1080/15265161.2021.1965254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
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Agtarap S, Kramer MD, Campbell-Sills L, Yuh E, Mukherjee P, Manley GT, McCrea MA, Dikmen S, Giacino JT, Stein MB, Nelson LD. Invariance of the Bifactor Structure of Mild Traumatic Brain Injury (mTBI) Symptoms on the Rivermead Postconcussion Symptoms Questionnaire Across Time, Demographic Characteristics, and Clinical Groups: A TRACK-TBI Study. Assessment 2021; 28:1656-1670. [PMID: 32326739 PMCID: PMC7584771 DOI: 10.1177/1073191120913941] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study aimed to elucidate the structure of the Rivermead Postconcussion Symptoms Questionnaire (RPQ) and evaluate its longitudinal and group variance. Factor structures were developed and compared in 1,011 patients with mild traumatic brain injury (mTBI; i.e., Glasgow Coma Scale score 13-15) from the Transforming Research and Clinical Knowledge in TBI study, using RPQ data collected at 2 weeks, and 3, 6, and 12 months postinjury. A bifactor model specifying a general factor and emotional, cognitive, and visual symptom factors best represented the latent structure of the RPQ. The model evinced strict measurement invariance over time and across sex, age, race, psychiatric history, and mTBI severity groups, indicating that differences in symptom endorsement were completely accounted for by these latent dimensions. While highly unidimensional, the RPQ has multidimensional features observable through a bifactor model, which may help differentiate symptom expression patterns in the future.
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Affiliation(s)
- Stephanie Agtarap
- Defense and Veterans Brain Injury Center, Naval Medical Center, San Diego, CA, USA
| | | | - Laura Campbell-Sills
- Defense and Veterans Brain Injury Center, Naval Medical Center, San Diego, CA, USA
| | - Esther Yuh
- University of California San Francisco, San Francisco, CA, USA
| | | | | | | | | | | | - Murray B Stein
- Defense and Veterans Brain Injury Center, Naval Medical Center, San Diego, CA, USA
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Wilson L, Boase K, Nelson LD, Temkin NR, Giacino JT, Markowitz AJ, Maas A, Menon DK, Teasdale G, Manley GT. A Manual for the Glasgow Outcome Scale-Extended Interview. J Neurotrauma 2021; 38:2435-2446. [PMID: 33740873 PMCID: PMC8390784 DOI: 10.1089/neu.2020.7527] [Citation(s) in RCA: 96] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The Glasgow Outcome Scale-Extended (GOSE) has become one of the most widely used outcome instruments to assess global disability and recovery after traumatic brain injury. Achieving consistency in the application of the assessment remains a challenge, particularly in multi-center studies involving many assessors. We present a manual for the GOSE interview that is designed to support both single- and multi-center studies and promote inter-rater agreement. Many patients fall clearly into a particular category; however, patients may have outcomes that are on the borderline between adjacent categories, and cases can present other challenges for assessment. The Manual includes the general principles of assessment, advice on administering each section of the GOSE interview, and guidance on "borderline" and "difficult" cases. Finally, we discuss the properties of the GOSE, including strengths and limitations, and outline recommendations for assessor training, accreditation, and monitoring.
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Affiliation(s)
- Lindsay Wilson
- Division of Psychology, School of Natural Sciences, University of Stirling, Stirling, United Kingdom
| | - Kim Boase
- Harborview Medical Center, Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | | | - Nancy R. Temkin
- Harborview Medical Center, Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | | | - Amy J. Markowitz
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, California, USA
| | - Andrew Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David K. Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Graham Teasdale
- Mental Health and Wellbeing in the Institute of Health and Wellbeing at the University of Glasgow Medical School, Glasgow, United Kingdom
| | - Geoffrey T. Manley
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, California, USA
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Boase K, Machamer J, Temkin NR, Dikmen S, Wilson L, Nelson LD, Barber J, Bodien YG, Giacino JT, Markowitz AJ, McCrea MA, Satris G, Stein MB, Taylor SR, Manley GT. Central Curation of Glasgow Outcome Scale-Extended Data: Lessons Learned from TRACK-TBI. J Neurotrauma 2021; 38:2419-2434. [PMID: 33832330 PMCID: PMC8390785 DOI: 10.1089/neu.2020.7528] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The Glasgow Outcome Scale (GOS) in its original or extended (GOSE) form is the most widely used assessment of global disability in traumatic brain injury (TBI) research. Several publications have reported concerns about assessor scoring inconsistencies, but without documentation of contributing factors. We reviewed 6801 GOSE assessments collected longitudinally, across 18 sites in the 5-year, observational Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study. We recorded error rates (i.e., corrections to a section or an overall rating) based on site assessor documentation and categorized scoring issues, which then informed further training. In cohort 1 (n = 1261; February 2014 to May 2016), 24% of GOSEs had errors identified by central review. In cohort 2 (n = 1130; June 2016 to July 2018), acquired after curation of cohort 1 data, feedback, and further training of site assessors, the error rate was reduced to 10%. GOSE sections associated with the most frequent interpretation and scoring difficulties included whether current functioning represented a change from pre-injury (466 corrected ratings in cohort 1; 62 in cohort 2), defining dependency in the home and community (163 corrections in cohort 1; three in cohort 2) and return to work/school (72 corrections in cohort 1; 35 in cohort 2). These results highlight the importance of central review in improving consistency across sites and over time. Establishing clear scoring criteria, coupled with ongoing guidance and feedback to data collectors, is essential to avoid scoring errors and resultant misclassification, which carry potential to result in "failure" of clinical trials that rely on the GOSE as their primary outcome measure.
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Affiliation(s)
- Kim Boase
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Joan Machamer
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Nancy R. Temkin
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Sureyya Dikmen
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Lindsay Wilson
- Division of Psychology, School of Natural Sciences, University of Stirling, Stirling, United Kingdom
| | - Lindsay D. Nelson
- Department of Neurological Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jason Barber
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Yelena G. Bodien
- Spaulding Rehabilitation Hospital Massachusetts General Hospital, Charlestown, Massachusetts, USA
| | - Joseph T. Giacino
- Spaulding Rehabilitation Hospital Massachusetts General Hospital, Charlestown, Massachusetts, USA
| | - Amy J. Markowitz
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, California, USA
| | - Michael A. McCrea
- Department of Neurological Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Gabriela Satris
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, California, USA
| | - Murray B. Stein
- Department of Psychiatry, University of California, San Diego, La Jolla, California, USA
| | - Sabrina R. Taylor
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, California, USA
| | - Geoffrey T. Manley
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, California, USA
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Abstract
Peripheral injuries are common in patients who experience mild traumatic brain injury (mTBI). However, the additive or interactive effects of polytrauma on psychosocial adjustment, functional limitations, and clinical outcomes after head injury remain relatively unexamined. Using a recently developed structured injury symptom interview, we assessed the perception and relative importance of peripheral injuries at 3 months post-injury in patients with mTBI as defined by the American Congress of Rehabilitation Medicine. Our sample of Level 1 trauma patients (n = 74) included individuals who were treated and released from the emergency department (n = 43) and those admitted to an inpatient unit (n = 31). Across the sample, 91% of patients with mTBI experienced additional non-head injuries known to commonly impact recovery following mTBI, a majority of whom ranked pain as their worst peripheral injury symptom. Forty-nine percent of the mTBI sample (54% of the subsample with concurrent mTBI and peripheral injuries) reported being more bothered by peripheral injury symptoms than mTBI. Differences between patients with mTBI with worse mTBI symptoms versus those with worse peripheral injury symptoms are described. Conventional measures of injury severity do not capture patients' perceptions of the totality of their injuries, which limits the development of patient-centered treatments. Future research should enroll patients with mTBI diverse in peripheral injury severity and develop standardized assessments to characterize peripheral symptoms, enabling better characterization of the relevance of concurrent injuries in recovery and outcomes of patients with mTBI.
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Affiliation(s)
- Andrew M. Bryant
- Departments of Neurology and Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Michael A. McCrea
- Departments of Neurology and Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lindsay D. Nelson
- Departments of Neurology and Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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McCrea MA, Giacino JT, Barber J, Temkin NR, Nelson LD, Levin HS, Dikmen S, Stein M, Bodien YG, Boase K, Taylor SR, Vassar M, Mukherjee P, Robertson C, Diaz-Arrastia R, Okonkwo DO, Markowitz AJ, Manley GT, Adeoye O, Badjatia N, Bullock MR, Chesnut R, Corrigan JD, Crawford K, Duhaime AC, Ellenbogen R, Feeser VR, Ferguson AR, Foreman B, Gardner R, Gaudette E, Goldman D, Gonzalez L, Gopinath S, Gullapalli R, Hemphill JC, Hotz G, Jain S, Keene CD, Korley FK, Kramer J, Kreitzer N, Lindsell C, Machamer J, Madden C, Martin A, McAllister T, Merchant R, Ngwenya LB, Noel F, Nolan A, Palacios E, Perl D, Puccio A, Rabinowitz M, Rosand J, Sander A, Satris G, Schnyer D, Seabury S, Sherer M, Toga A, Valadka A, Wang K, Yue JK, Yuh E, Zafonte R. Functional Outcomes Over the First Year After Moderate to Severe Traumatic Brain Injury in the Prospective, Longitudinal TRACK-TBI Study. JAMA Neurol 2021; 78:982-992. [PMID: 34228047 DOI: 10.1001/jamaneurol.2021.2043] [Citation(s) in RCA: 90] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Importance Moderate to severe traumatic brain injury (msTBI) is a major cause of death and disability in the US and worldwide. Few studies have enabled prospective, longitudinal outcome data collection from the acute to chronic phases of recovery after msTBI. Objective To prospectively assess outcomes in major areas of life function at 2 weeks and 3, 6, and 12 months after msTBI. Design, Setting, and Participants This cohort study, as part of the Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study, was conducted at 18 level 1 trauma centers in the US from February 2014 to August 2018 and prospectively assessed longitudinal outcomes, with follow-up to 12 months postinjury. Participants were patients with msTBI (Glasgow Coma Scale scores 3-12) extracted from a larger group of patients with mild, moderate, or severe TBI who were enrolled in TRACK-TBI. Data analysis took place from October 2019 to April 2021. Exposures Moderate or severe TBI. Main Outcomes and Measures The Glasgow Outcome Scale-Extended (GOSE) and Disability Rating Scale (DRS) were used to assess global functional status 2 weeks and 3, 6, and 12 months postinjury. Scores on the GOSE were dichotomized to determine favorable (scores 4-8) vs unfavorable (scores 1-3) outcomes. Neurocognitive testing and patient reported outcomes at 12 months postinjury were analyzed. Results A total of 484 eligible patients were included from the 2679 individuals in the TRACK-TBI study. Participants with severe TBI (n = 362; 283 men [78.2%]; median [interquartile range] age, 35.5 [25-53] years) and moderate TBI (n = 122; 98 men [80.3%]; median [interquartile range] age, 38 [25-53] years) were comparable on demographic and premorbid variables. At 2 weeks postinjury, 36 of 290 participants with severe TBI (12.4%) and 38 of 93 participants with moderate TBI (41%) had favorable outcomes (GOSE scores 4-8); 301 of 322 in the severe TBI group (93.5%) and 81 of 103 in the moderate TBI group (78.6%) had moderate disability or worse on the DRS (total score ≥4). By 12 months postinjury, 142 of 271 with severe TBI (52.4%) and 54 of 72 with moderate TBI (75%) achieved favorable outcomes. Nearly 1 in 5 participants with severe TBI (52 of 270 [19.3%]) and 1 in 3 with moderate TBI (23 of 71 [32%]) reported no disability (DRS score 0) at 12 months. Among participants in a vegetative state at 2 weeks, 62 of 79 (78%) regained consciousness and 14 of 56 with available data (25%) regained orientation by 12 months. Conclusions and Relevance In this study, patients with msTBI frequently demonstrated major functional gains, including recovery of independence, between 2 weeks and 12 months postinjury. Severe impairment in the short term did not portend poor outcomes in a substantial minority of patients with msTBI. When discussing prognosis during the first 2 weeks after injury, clinicians should be particularly cautious about making early, definitive prognostic statements suggesting poor outcomes and withdrawal of life-sustaining treatment in patients with msTBI.
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Affiliation(s)
- Michael A McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts.,Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston.,Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle
| | - Nancy R Temkin
- Department of Neurological Surgery, University of Washington, Seattle
| | - Lindsay D Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
| | - Harvey S Levin
- Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
| | - Sureyya Dikmen
- Department of Neurological Surgery, University of Washington, Seattle
| | - Murray Stein
- Department of Family Medicine and Public Health, University of California, San Diego, San Diego
| | - Yelena G Bodien
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts.,Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston.,Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
| | - Kim Boase
- Department of Neurological Surgery, University of Washington, Seattle
| | - Sabrina R Taylor
- Neurological Surgery, University of California, San Francisco, San Francisco
| | - Mary Vassar
- Neurological Surgery, University of California, San Francisco, San Francisco
| | - Pratik Mukherjee
- Neurological Surgery, University of California, San Francisco, San Francisco
| | - Claudia Robertson
- Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
| | | | - David O Okonkwo
- Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Amy J Markowitz
- Neurological Surgery, University of California, San Francisco, San Francisco
| | - Geoffrey T Manley
- Neurological Surgery, University of California, San Francisco, San Francisco
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Sonia Jain
- University of California, San Diego, La Jolla
| | | | | | - Joel Kramer
- University of California, San Francisco, San Francisco
| | | | | | | | | | | | | | | | | | | | - Amber Nolan
- University of California, San Francisco, San Francisco
| | - Eva Palacios
- University of California, San Francisco, San Francisco
| | - Daniel Perl
- Uniformed Services University, Bethesda, Maryland
| | - Ava Puccio
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | | | | | | | | | | | - Arthur Toga
- University of Southern California, Los Angeles
| | | | | | - John K Yue
- University of California, San Francisco, San Francisco
| | - Esther Yuh
- University of California, San Francisco, San Francisco
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