Correction: Development of Therapeutic Alliance and Social Presence in a Digital Intervention for Pediatric Concussion: Qualitative Exploratory Study

[This corrects the article DOI: 10.2196/49133.].

Litigation, Performance Validity Testing, and Treatment Outcomes in Adults With Mild Traumatic Brain Injury

OBJECTIVE

To investigate whether involvement in litigation and performance validity test (PVT) failure predict adherence to treatment and treatment outcomes in adults with persistent symptoms after mild traumatic brain injury (mTBI).

SETTING

Outpatient concussion clinics in British Columbia, Canada. Participants were assessed at intake (average 12.9 weeks postinjury) and again following 3 to 4 months of rehabilitation.

PARTICIPANTS

Adults who met the World Health Organization Neurotrauma Task Force definition of mTBI. Litigation status was known for 69 participants ( n = 21 reported litigation), and 62 participants completed a PVT ( n = 13 failed the Test of Memory Malingering) at clinic intake.

DESIGN

Secondary analysis of a clinical trial (ClinicalTrials.gov #NCT03972579).

MAIN MEASURES

Outcomes included number of completed sessions, homework adherence, symptoms (Rivermead Post Concussion Symptoms Questionnaire), disability ratings (World Health Organization Disability Assessment Schedule 2.0), and patient-rated global impression of change.

RESULTS

We did not observe substantial differences in session and homework adherence associated with litigation or PVT failure. Disability and postconcussion symptoms generally improved with treatment. Involvement in litigation was associated with a smaller improvement in outcomes, particularly disability ( B = 2.57, 95% confidence interval [CI] [0.25-4.89], P = .03) and patient-reported global impression of change (odds ratio [OR] = 4.19, 95% CI [1.40-12.57], P = .01). PVT failure was not associated with considerable differences in treatment outcomes. However, participants who failed the PVT had a higher rate of missing outcomes (31% vs 8%) and perceived somewhat less global improvement (OR = 3.47, 95% CI [0.86-14.04]; P = .08).

CONCLUSION

Adults with mTBI who are in litigation or who failed PVTs tend to adhere to and improve following treatment. However, involvement in litigation may be associated with attenuated improvements, and pretreatment PVT failure may predict lower engagement in the treatment process.

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

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

Development of Therapeutic Alliance and Social Presence in a Digital Intervention for Pediatric Concussion: Qualitative Exploratory Study

BACKGROUND

Despite the promising benefits of self-guided digital interventions for adolescents recovering from concussion, attrition rates for such interventions are high. Evidence suggests that adults can develop therapeutic alliance with self-guided digital interventions, which is in turn associated with intervention engagement. However, no research has examined whether adolescents develop therapeutic alliance with self-guided digital interventions and what factors are important to its development. Additionally, social presence-the extent to which digital encounters feel like they are occurring in person-may be another relevant factor to understanding the nature of the connection between adolescents and a self-guided digital intervention, though this has yet to be explored.

OBJECTIVE

This qualitative study explored the extent to which adolescents recovering from concussion developed therapeutic alliance and social presence during their use of a self-guided digital mindfulness-based intervention. Additionally, this study aimed to determine factors important to adolescents' development of therapeutic alliance and social presence with the intervention.

METHODS

Adolescents aged between 12 and 17.99 years who sustained a concussion were recruited from 2 sites: a pediatric emergency department up to 48 hours after a concussion and a tertiary care clinic over 1 month following a concussion to capture adolescents who had both acute and persisting symptoms after concussion. Participants (N=10) completed a 4-week mindfulness-based intervention delivered through a smartphone app. Within the app, participants listened to audio recordings of mindfulness guides (voice actors) narrating psychoeducation and mindfulness practices. At 4 weeks, participants completed questionnaires and a semistructured interview exploring their experience of therapeutic alliance and social presence with the mindfulness guides in the intervention.

RESULTS

Themes identified within the qualitative results revealed that participants developed therapeutic alliance and social presence by "developing a genuine connection" with their mindfulness guides and "sensing real people." Particularly important to the development of therapeutic alliance and social presence were the mindfulness guides' "personal backgrounds and voices," such that participants felt more connected to the guides by knowing information about them and through the guides' calm tone of voice in audio recordings. Quantitative findings supported qualitative results; participants' average score for therapeutic alliance was far above the scale midpoint, while the mixed results for social presence measures aligned with qualitative findings that participants felt that the mindfulness guides seemed real but not quite as real as an in-person connection would.

CONCLUSIONS

Our data suggest that adolescents can develop therapeutic alliance and social presence when using digital interventions with no direct human contact. Adolescents' development of therapeutic alliance and social presence with self-guided digital interventions can be bolstered by increasing human-like qualities (eg, real voices) within interventions. Maximizing therapeutic alliance and social presence may be a promising way to reduce attrition in self-guided digital interventions while providing accessible treatment.

External Validation of the Post-Concussion Symptoms Rule for Predicting Mild Traumatic Brain Injury Outcome

Persistent symptoms are common after a mild traumatic brain injury (mTBI). The Post-Concussion Symptoms (PoCS) Rule is a newly developed clinical decision rule for the prediction of persistent post-concussion symptoms (PPCS) 3 months after an mTBI. The PoCS Rule includes assessment of demographic and clinical characteristics and headache presence in the emergency department (ED), and follow-up assessment of symptoms at 7 days post-injury using two thresholds (lower/higher) for symptom scoring. We examined the PoCS Rule in an independent sample. We analyzed a clinical trial that recruited participants with mTBI from EDs in Greater Vancouver, Canada. The primary analysis used data from 236 participants, who were randomized to a usual care control group, and completed the Rivermead Postconcussion Symptoms Questionnaire at 3 months. The primary outcome was PPCS, as defined by the PoCS authors. We assessed the overall performance of the PoCS rule (area under the receiver operating characteristic curve [AUC]), sensitivity, and specificity. More than 40% of participants (median age 38 years, 59% female) reported PPCS at 3 months. Most participants (88%) were categorized as being at medium risk based on the ED assessment, and a majority were considered as being at high risk according to the final PoCS Rule (81% using a lower threshold and 72% using a higher threshold). The PoCS Rule showed a sensitivity of 93% (95% confidence interval [CI], 88-98; lower threshold) and 85% (95% CI, 78-92; higher threshold), and a specificity of 28% (95% CI, 21-36) and 37% (95% CI, 29-46), respectively. The overall performance was modest (AUC 0.61, 95% CI 0.59, 0.65). In conclusion, the PoCS Rule was sensitive for PPCS, but had a low specificity in our sample. Follow-up assessment of symptoms can improve risk stratification after mTBI.

Neuropsychological evaluation of functional cognitive disorder: A narrative review

Objective: To critically review contemporary theoretical models, diagnostic approaches, clinical features, and assessment findings in Functional Cognitive Disorder (FCD), and make recommendations for neuropsychological evaluation of this condition. Method: Narrative review. Results: FCD is common in neuropsychological practice. It is characterized by cognitive symptoms that are not better explained by another medical or psychiatric disorder. The cognitive symptoms are associated with distress and/or limitations in daily functioning, but are potentially reversible with appropriate identification and treatment. Historically, a variety of diagnostic frameworks have attempted to capture this condition. A contemporary conceptualization of FCD positions it as a subtype of Functional Neurological Disorder, with shared and unique etiological factors. Patients with FCD tend to perform normally on neuropsychological testing or demonstrate relatively weak memory acquisition (e.g. list learning trials) in comparison to strong attention and delayed recall performance. Careful history-taking and behavioral observations are essential to support the diagnosis of FCD. Areas of ongoing controversy include operationalizing "internal inconsistencies" and the role of performance validity testing. Evidence for targeted interventions remains scarce. Conclusions: Neuropsychologists familiar with FCD can uniquely contribute to the care of patients with this condition by improving diagnostic clarity, richening case formulation, communicating effectively with referrers, and leading clinical management. Further research is needed to refine diagnosis, prognosis, and treatment.

Catastrophizing is associated with excess cognitive symptom reporting after mild traumatic brain injury

OBJECTIVE

Persistent cognitive symptoms after mild traumatic brain injury (mTBI) often do not correlate with objective neuropsychological performance. Catastrophizing (i.e., excessively negative interpretations of symptoms) may help explain this discrepancy. We hypothesize that symptom catastrophizing will be associated with greater cognitive symptom reporting relative to neuropsychological test performance in people seeking treatment for mTBI.

METHOD

Secondary analysis of baseline data from a randomized controlled trial. Adults with mTBI (N = 77) were recruited from two outpatient mTBI clinics in British Columbia, Canada. Questionnaires and assessments were administered at baseline (M = 17.7 weeks postinjury). The sample was 64% women with a mean age of 42 years (SD = 11.5). Validated questionnaires were used to assess catastrophizing, cognitive symptoms, and affective distress. Neuropsychological performance was assessed using the National Institutes of Health Toolbox Cognition Battery. Discrepancies between cognitive symptoms and cognitive functioning were operationalized using standard residuals from neuropsychological test performance scores regressed on cognitive symptom scores. Generalized linear models were run to measure the association between symptom catastrophizing, cognitive variables, and their discrepancy, with affective distress as a covariate.

RESULTS

Symptom catastrophizing was associated with more severe cognitive symptoms when controlling for neuropsychological performance (β = 0.44, 95% CI [0.23, 0.65]). Symptom catastrophizing was also associated with higher subjective-objective cognition residuals (β = 0.43, 95% CI [0.22, 0.64]). Catastrophizing remained a significant predictor after affective distress was introduced as a covariate.

CONCLUSIONS

Catastrophizing is associated with misperceptions of cognitive functioning following mTBI, specifically overreporting cognitive symptoms relative to neuropsychological performance. Symptom catastrophizing may be an important determinant of cognitive symptom reporting months after mTBI. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Factors perpetuating functional cognitive symptoms after mild traumatic brain injury

INTRODUCTION

Self-reported memory difficulties (forgetting familiar names, misplacing objects) often persist long after a mild traumatic brain injury (mTBI), despite normal neuropsychological test performance. This clinical presentation may be a manifestation of a functional cognitive disorder (FCD). Several mechanisms underlying FCD have been proposed, including metacognitive impairment, memory perfectionism, and misdirected attention, as well as depression or anxiety-related explanations. This study aims to explore these candidate perpetuating factors in mTBI, to advance our understanding of why memory symptoms frequently persist following mTBI.

METHODS

A cross-sectional study of 67 adults (n = 39 with mTBI mean = 25 months ago and n = 28 healthy controls). Participants completed standardized questionnaires (including the Functional Memory Disorder Inventory), a metacognitive task (to quantify discrepancies between their trial-by-trial accuracy and confidence), and a brief neuropsychological test battery. We assessed candidate mechanisms in two ways: (1) between-groups, comparing participants with mTBI to healthy controls, and (2) within-group, examining their associations with functional memory symptom severity (FMDI) in the mTBI group.

RESULTS

Participants with mTBI performed similarly to controls on objective measures of memory ability but reported experiencing much more frequent memory lapses in daily life. Contrary to expectations, metacognitive efficiency did not differentiate the mTBI and control groups and was not associated with functional memory symptoms. Memory perfectionism was strongly associated with greater functional memory symptoms among participants with mTBI but did not differ between groups when accounting for age. Depression and checking behaviors produced consistent results across between-groups and within-group analyses: these factors were greater in the mTBI group compared to the control group and were associated with greater functional memory symptoms within the mTBI group.

CONCLUSIONS

This study highlights promising (e.g., depression, checking behaviors) and unlikely (e.g., metacognitive impairment) mechanisms underlying functional memory symptoms after mTBI, to guide future research and treatment.

Three-month Practice Effect of the National Institutes of Health Toolbox Cognition Battery in Young Healthy Adults

The National Institutes of Health Toolbox-Cognition Battery (NIHTB-CB) is a tablet-based cognitive assessment intended for individuals with neurological diseases of all ages. NIHTB-CB practice effects (PEs), however, need clarification if this measure is used to track longitudinal change. We explored the test-retest PEs on NIHTB-CB performance at 3 months in young healthy adults (n = 22). We examined corrected T-scores normalized for demographic factors and calculated PEs using Cohen's d. There were significant PEs for all NIHTB-CB composite scores and on 4/7 subtests. This work suggests the need to further assess NIHTB-CB PEs as this may affect the interpretation of study results incorporating this battery.

Rest and exercise early after sport-related concussion: a systematic review and meta-analysis

OBJECTIVE

To synthesise the evidence regarding the risks and benefits of physical activity (PA), prescribed aerobic exercise treatment, rest, cognitive activity and sleep during the first 14 days after sport-related concussion (SRC).

DESIGN

Meta-analysis was performed for PA/prescribed exercise interventions and a narrative synthesis for rest, cognitive activity and sleep. Risk of bias (ROB) was determined using the Scottish Intercollegiate Guidelines Network and quality assessed using Grading of Recommendations, Assessment, Development and Evaluations.

DATA SOURCES

MEDLINE, Embase, APA PsycInfo, Cochrane Central Register of Controlled Trials, CINAHL Plus and SPORTDiscus. Searches were conducted in October 2019 and updated in March 2022.

ELIGIBILITY CRITERIA

Original research articles with sport-related mechanism of injury in >50% of study sample and that evaluated how PA, prescribed exercise, rest, cognitive activity and/or sleep impact recovery following SRC. Reviews, conference proceedings, commentaries, editorials, case series, animal studies and articles published before 1 January 2001 were excluded.

RESULTS

46 studies were included and 34 had acceptable/low ROB. Prescribed exercise was assessed in 21 studies, PA in 15 studies (6 PA/exercise studies also assessed cognitive activity), 2 assessed cognitive activity only and 9 assessed sleep. In a meta-analysis of seven studies, PA and prescribed exercise improved recovery by a mean of -4.64 days (95% CI -6.69, -2.59). After SRC, early return to light PA (initial 2 days), prescribed aerobic exercise treatment (days 2-14) and reduced screen use (initial 2 days) safely facilitate recovery. Early prescribed aerobic exercise also reduces delayed recovery, and sleep disturbance is associated with slower recovery.

CONCLUSION

Early PA, prescribed aerobic exercise and reduced screen time are beneficial following SRC. Strict physical rest until symptom resolution is not effective, and sleep disturbance impairs recovery after SRC.

PROSPERO REGISTRATION NUMBER

CRD42020158928.

Targeted interventions and their effect on recovery in children, adolescents and adults who have sustained a sport-related concussion: a systematic review

OBJECTIVES

We evaluated interventions to facilitate recovery in children, adolescents and adults with a sport-related concussion (SRC).

DESIGN

Systematic review including risk of bias (modified Scottish Intercollegiate Guidelines Network tool).

DATA SOURCES

MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Embase, APA PsycINFO, Cochrane Central Register of Controlled Trials, CINAHL Plus with Full Text, SPORTDiscus and Scopus searched until March 2022.

STUDY ELIGIBILITY CRITERIA

(1) Original research including randomised controlled trials (RCTs), quasi-experimental designs, cohort, comparative effectiveness studies; (2) focus on SRC; (3) English; (4) peer-reviewed and (5) evaluated treatment.

RESULTS

6533 studies were screened, 154 full texts reviewed and 13 met inclusion (10 RCTs, 1 quasi-experimental and 2 cohort studies; 1 high-quality study, 7 acceptable and 5 at high risk of bias). Interventions, comparisons, timing and outcomes varied, precluding meta-analysis. For adolescents and adults with dizziness, neck pain and/or headaches >10 days following concussion, individualised cervicovestibular rehabilitation may decrease time to return to sport compared with rest followed by gradual exertion (HR 3.91 (95% CI 1.34 to 11.34)) and when compared with a subtherapeutic intervention (HR 2.91 (95% CI 1.01 to 8.43)). For adolescents with vestibular symptoms/impairments, vestibular rehabilitation may decrease time to medical clearance (vestibular rehab group 50.2 days (95% CI 39.9 to 60.4) compared with control 58.4 (95% CI 41.7 to 75.3) days). For adolescents with persisting symptoms >30 days, active rehabilitation and collaborative care may decrease symptoms.

CONCLUSIONS

Cervicovestibular rehabilitation is recommended for adolescents and adults with dizziness, neck pain and/or headaches for >10 days. Vestibular rehabilitation (for adolescents with dizziness/vestibular impairments >5 days) and active rehabilitation and/or collaborative care (for adolescents with persisting symptoms >30 days) may be of benefit.

The American Congress of Rehabilitation Medicine Diagnostic Criteria for Mild Traumatic Brain Injury

OBJECTIVE

To develop new diagnostic criteria for mild traumatic brain injury (TBI) that are appropriate for use across the lifespan and in sports, civilian trauma, and military settings.

DESIGN

Rapid evidence reviews on 12 clinical questions and Delphi method for expert consensus.

PARTICIPANTS

The Mild Traumatic Brain Injury Task Force of the American Congress of Rehabilitation Medicine Brain Injury Special Interest Group convened a Working Group of 17 members and an external interdisciplinary expert panel of 32 clinician-scientists. Public stakeholder feedback was analyzed from 68 individuals and 23 organizations.

RESULTS

The first two Delphi votes asked the expert panel to rate their agreement with both the diagnostic criteria for mild TBI and the supporting evidence statements. In the first round, 10 of 12 evidence statements reached consensus agreement. Revised evidence statements underwent a second round of expert panel voting, where consensus was achieved for all. For the diagnostic criteria, the final agreement rate, after the third vote, was 90.7%. Public stakeholder feedback was incorporated into the diagnostic criteria revision prior to the third expert panel vote. A terminology question was added to the third round of Delphi voting, where 30 of 32 (93.8%) expert panel members agreed that 'the diagnostic label 'concussion' may be used interchangeably with 'mild TBI' when neuroimaging is normal or not clinically indicated.'

CONCLUSIONS

New diagnostic criteria for mild TBI were developed through an evidence review and expert consensus process. Having unified diagnostic criteria for mild TBI can improve the quality and consistency of mild TBI research and clinical care.

Responsiveness and trajectory of changes in the rating of everyday arm-use in the community and home (REACH) scale over the first-year post-stroke

OBJECTIVE

To examine the trajectory of the Rating of Everyday Arm-use in the Community and Home (REACH) scores over the first-year post-stroke, determine if REACH scores are modified by baseline impairment level and explore the responsiveness of the REACH scale through hypothesis testing.

DESIGN

Consecutive sample longitudinal study.

SETTING

Participants were recruited from an acute stroke unit and followed up at three, six, and 12 months post-stroke.

PARTICIPANTS

Seventy-three participants with upper limb weakness (Shoulder Abduction and Finger Extension score ≤ 8).

MAIN MEASURES

The REACH scale is a six-level self-report classification scale that captures how the affected upper limb is being used in one's own environment. The Fugl-Meyer Upper Limb Assessment (FMA-UL), Stroke Upper Limb Capacity Scale (SULCS), accelerometer-based activity count ratio and Global Rating of Change Scale (GRCS) were used to capture upper limb impairment, capacity, and use.

RESULTS

The following proportions of participants improved at least one REACH level: 64% from baseline to three months, 37% from three to six months and 13% from six to 12 months post-stroke. The trajectory of REACH scores over time was associated with baseline impairment. Change in REACH had a moderate correlation to change in SULCS and the GRCS but not FMA-UL or the activity count ratio.

CONCLUSIONS

Results of hypothesis testing provide preliminary evidence of the responsiveness of the REACH scale. On average, individuals with severe impairment continued to show improvement in use over the first year, while those with mild/moderate impairment plateaued and a small proportion decreased in the early chronic phase.

Psychological Contributions to Symptom Provocation Testing After Concussion

OBJECTIVE

Following concussion, symptoms such as headache, dizziness, and fatigue may transiently worsen or reemerge with increased exertion or activity. Standardized tests have been developed to assess symptom increases following aerobic, cognitive, or vestibular/oculomotor challenge. Although neurophysiological mechanisms are proposed to underlie symptom increases following exertion, psychological factors such as anxiety and misinterpretation of normal bodily sensations may also play a role. In this study, we examined the contribution of psychological factors to symptom provocation testing outcomes.

SETTING

Two outpatient concussion clinics in British Columbia, Canada.

PARTICIPANTS

Adults with persistent symptoms following concussion ( N = 79; 62% women).

DESIGN

In a single session, participants completed self-report questionnaires measuring the psychological factors of interest and underwent symptom provocation testing including aerobic (Buffalo Concussion Bike Test; BCBT), cognitive (National Institutes of Health Toolbox-Cognition Battery; NIHTB-CB), and vestibular/oculomotor (Vestibular/Ocular Motor Screening for Concussion; VOMS) challenge.

MAIN MEASURES

Psychological factors of interest included premorbid and current anxiety (Generalized Anxiety Disorder-7; GAD-7), catastrophizing (Pain Catastrophizing Scale-Adapted; PCS-A), fear avoidance behavior (Fear Avoidance Behavior after Traumatic Brain Injury; FAB-TBI), and somatization (Patient Health Questionnaire-15; PHQ-15). Our primary outcome variables were self-reported symptom change during each symptom provocation test.

RESULTS

We found that current anxiety ( B = 0.034; 95% CI = 0.003, 0.065), symptom catastrophizing ( B = 0.013; 95% CI = 0.000, 0.026), fear avoidance behavior ( B = 0.029; 95% CI = 0.008, 0.050), and somatization ( B = 0.041; 95% CI = 0.007, 0.075) were associated with increased symptoms during the VOMS in univariate models adjusted for time postinjury but not in a multivariable model that included all covariates. The psychological variables of interest were not significantly related to symptom change during the BCBT or NIHTB-CB.

CONCLUSION

Our findings suggest that symptom provocation test failure should be interpreted with caution because it might indicate psychological maladjustment rather than lingering brain injury or incomplete neurophysiological recovery.

Management of Psychological Complications Following Mild Traumatic Brain Injury

PURPOSE OF REVIEW

It has been clear for decades that psychological factors often contribute to mild traumatic brain injury (mTBI) outcome, but an emerging literature has begun to clarify which specific factors are important, when, for whom, and how they impact recovery. This review aims to summarize the contemporary evidence on psychological determinants of recovery from mTBI and its implications for clinical management.

RECENT FINDINGS

Comorbid mental health disorders and specific illness beliefs and coping behaviors (e.g., fear avoidance) are associated with worse recovery from mTBI. Proactive assessment and intervention for psychological complications can improve clinical outcomes. Evidence-based treatments for primary mental health disorders are likely also effective for treating mental health disorders after mTBI, and can reduce overall post-concussion symptoms. Broad-spectrum cognitive-behavioral therapy may modestly improve post-concussion symptoms, but tailoring delivery to individual psychological risk factors and/or symptoms may improve its efficacy. Addressing psychological factors in treatments delivered primarily by non-psychologists is a promising and cost-effective approach for enhancing clinical management of mTBI. Recent literature emphasizes a bio-psycho-socio-ecological framework for understanding mTBI recovery and a precision rehabilitation approach to maximize recovery. Integrating psychological principles into rehabilitation and tailoring interventions to specific risk factors may improve clinical management of mTBI.

Fear avoidance and return to work after mild traumatic brain injury

OBJECTIVES

Fear avoidance is associated with symptom persistence after mild traumatic brain injury (mTBI). In this study, we investigated whether fear avoidance was associated with other outcomes such as return to work-related activity (RTW).

MATERIALS AND METHODS

We analyzed associations between fear avoidance and RTW 6-9 months after mTBI, in two merged prospective mTBI cohorts. Adult participants aged 16 or over (n=175), presenting to outpatient services in New Zealand within 3 months of their injury, who were engaged in work-related activity at the time of injury, were included. Participants completed the Fear Avoidance Behavior after Traumatic Brain Injury (FAB-TBI) questionnaire at enrollment and 6 months later. Associations between FAB-TBI scores and RTW outcome were analyzed using multivariate approaches.

RESULTS

Overall, 53% of participants had RTW by 6-9 months after mTBI. While early fear avoidance was weakly associated with RTW, persistent high fear avoidance between study assessments or increasing avoidance with time were associated with greater odds of still being off work 6-9 months after injury.

CONCLUSIONS

Pervasive and increasing avoidance of symptom triggers after mTBI were associated with lower rates of RTW 6-9 months after mTBI. Further research is needed to better understand transition points along the recovery trajectory where fear avoidance behaviors fade or increase after mTBI.

The Impact of a Recent Concussion on College-Aged Individuals with Co-Occurring Anxiety: A Qualitative Investigation

College-aged individuals with anxiety are vulnerable to developing persistent concussion symptoms, yet evidence-based treatments for this population are limited. Understanding these individuals' perspectives is critical for developing effective interventions. We conducted qualitative interviews with 17 college-aged individuals (18-24 years old) with a recent (≤10 weeks) concussion and at least mild anxiety (≥5 on the GAD-7 questionnaire) to understand the life impact of their concussion. We identified 5 themes: (1) disruption to daily activities (e.g., reduced participation in hobbies and physical activity); (2) disruption to relationships (e.g., reduced social engagement, feeling dismissed by others, stigma, and interpersonal friction); (3) disruptions in school/work (e.g., challenges participating due to light sensitivity, cognitive or sleep disturbance, and related emotional distress); (4) changes in view of the self (e.g., feeling "unlike oneself", duller, or more irritable), and (5) finding "silver linings" after the injury (e.g., increased motivation). Concussions impact the lives of college-aged individuals with co-occurring anxiety in a broad range of domains, many of which remain largely neglected in standard concussion clinical assessment and treatment. Assessing and addressing these issues has the potential to limit the negative impact of concussion, promote recovery, and potentially help prevent persistent concussion symptoms in this at-risk population.

Post-Concussion Symptoms and Disability in Adults with Mild Traumatic Brain Injury: A Systematic Review and Meta-Analysis

Studies investigating long-term symptoms and disability after mild traumatic brain injury (mTBI) have yielded mixed results. This systematic review and meta-analysis aimed to determine the prevalence of self-reported post-concussion symptoms (PCS) and disability following mTBI. We systematically searched MEDLINE, Embase, CINAHL, CENTRAL, and PsycInfo to identify inception cohort studies of adults with mTBI. Paired reviewers independently extracted data and assessed risk of bias with the Scottish Intercollegiate Guidelines Network criteria. We identified 43 eligible studies for the systematic review; 41 were rated as high risk of bias, primarily due to high attrition (> 20%). Twenty-one studies (49%) were included in the meta-analyses (five studies were narratively synthesized; 17 studies were duplicate reports). At 3-6 months post-injury, the estimated prevalence of PCS from random-effects meta-analyses was 31.3% (95% confidence interval [CI] = 25.4-38.4) using a lenient definition of PCS (2-4 mild severity PCS) and 18.3% (95% CI = 13.6-24.0) using a more stringent definition. The estimated prevalence of disability was 54.0% (95% CI = 49.4-58.6) and 29.6% (95% CI = 27.8-31.5) when defined as Glasgow Outcome Scale-Extended <8 and <7, respectively. The prevalence of symptoms similar to PCS was higher in adults with mTBI versus orthopedic injury (prevalence ratio = 1.57, 95% CI = 1.22-2.02). In a meta-regression, attrition rate was the only study-related factor significantly associated with higher estimated prevalence of PCS. Setting attrition to 0%, the estimated prevalence of PCS (lenient definition) was 16.1%. We conclude that nearly one in three adults who present to an emergency department or trauma center with mTBI report at least mild severity PCS 3-6 months later, but controlling for attrition bias, the true prevalence may be one in six. Studies with representative samples and high retention rates are needed.

The importance of screening for functional neurological disorders in patients with persistent post-concussion symptoms

BACKGROUND

Functional neurological disorder (FND) may commonly co-occur with persistent symptoms following a psychological trauma or physical injury such as concussion.

OBJECTIVE

To explore the occurrence of FND in a population with persistent post-concussion symptoms (PPCS) and the associations between FND and depression as well as anxiety in participants with PPCS.

METHODS

Sixty-three individuals with PPCS presenting to a specialized brain injury clinic completed the following questionnaires: screening for somatoform disorder conversion disorder subscale (SOM-CD), Rivermead post-concussion symptom questionnaire (RPQ), patient health questionnaire-9 (PHQ-9), and generalized anxiety disorder questionnaire- 7 (GAD-7). Both multiple linear regression and logistic regression were conducted to evaluate the relationship between questionnaires and adjust for covariates.

RESULTS

We found that total RPQ score (βˆ= 0.27; 95% CI = [0.16, 0.38]), GAD-7 score (βˆ= 0.71; 95% CI = [0.50, 0.92]) and PHQ-9 score (βˆ= 0.54; 95% CI = [0.32, 0.76]) were positively associated with SOM-CD score individually, after consideration of other covariates. Participants meeting the criteria for severe FND symptoms were 4.87 times more likely to have high PPCS symptom burden (95% CI = [1.57, 22.84]), 8.95 times more likely to have severe anxiety (95% CI = [3.31, 35.03]) and 4.11 times more likely to have severe depression symptom burden (95% CI = [1.77, 11.53]).

CONCLUSION

The findings of this study indicate an association between FND and post-concussion symptoms as well as an association between FND and symptoms of depression and anxiety in patients with PPCS. Patients with PPCS should be screened for FND to provide a more targeted treatment approach that includes somatic-focused interventions.

Derivation of a minimal clinically important difference score for the WHODAS 2.0 in mild traumatic brain injury

BACKGROUND

Mild traumatic brain injury (mTBI) treatment research is hindered by lack of clinically meaningful and responsive outcome measures. One promising measure is the World Health Organisation Disability Assessment Schedule 2.0 (WHODAS 2.0), although minimal clinically important differences (MCID) for have not been established.

OBJECTIVE

To estimate MCID for the WHODAS 2.0 for mTBI.

METHODS

We analysed two prospectively collected mTBI datasets (n = 225) attending adult outpatient clinics in British Columbia, Canada. Participants completed the 12-item WHODAS 2.0, Patient Global Impression of Change scale, and Rivermead Post-Concussion Symptoms Questionnaire. We used anchor- and distribution-based methods to explore MCIDs in WHODAS 2.0 scores.

RESULTS

For Study 1 (n = 131), the anchor and distribution-based approaches produced minimal change estimates ranging from 1.3 to 2.8 interval scores. For Study 2 (n = 94), the anchor and distribution-based approaches produced minimal change estimates from 2.2 to 3.2 interval scores. For certain subgroups based on age, sex, and post-concussion severity, minimal change estimates were slightly higher.

CONCLUSION

An MCID of 3.5 interval WHODAS 2.0 points would conservatively capture meaningful change in adults of varying age, sex, and post-concussion symptom severity. Such a uniform metric will assist future mTBI intervention studies to improve standards of care and evaluation of outcomes.

Rate of perceived stability as a measure of balance exercise intensity in people post-stroke

PURPOSE

This study investigates the reproducibility and concurrent validity of the Rate of Perceived Stability (RPS) Scale in people with stroke.

METHODS

On two separate days (2-10 days apart), participants provided their RPS ratings during clinical measures: 1)16 tasks from Community Balance and Mobility Scale (CB&M), 2)6-minute walk test (6MWT), and 3)self-paced gait speed. Intraclass correlations (ICCs) assessed between day test-retest reliability of RPS ratings. Standard error of measurement (SEM) and smallest detectable change (SDC) addressed level of between day agreement. Spearman rank correlations (r_s) quantified relationships between RPS, and general rating of perceived challenge, task-performance scores.

RESULTS

Thirty participants with stroke (50% female) participated. ICC ranged from 0.46 to 0.93 across tasks with 12/19 tasks showing ICCs above 0.75 (good test-retest reliability). SEM was 1-point for each task and SDC ranged from 2 to 4 across tasks. Concurrent validity between RPS and ratings of perceived challenge was good-to-excellent (r_s ranged 0.78-0.94, p < 0.01). Higher RPS (indicative of feeling less stable) was associated with lower balance performance scores on CB&M tasks, negative relationships ranged in strength from fair to good-to-excellent in 10/16 tasks (r_s ranged -0.46 to -0.81, p ≤ 0.01).

CONCLUSIONS

RPS shows promise as a measure of balance intensity in people with stroke.IMPLICATIONS FOR REHABILITATIONThe RPS is a reliable and valid measure of balance intensity in ambulatory people with stroke.The RPS scale may be a useful clinical tool to address the gap in practice of measuring balance intensity during rehabilitation of walking balance post-stroke.

Attachment and Clinical Outcomes Among Treatment-Seeking Adults With Persistent Symptoms After Mild Traumatic Brain Injury

OBJECTIVE

Interpersonal attachment influences the development and course of disease. Overreliance on insecure attachment strategies may increase risk for poor disease outcomes. This study aimed to investigate largely unexplored relationships between attachment strategies and clinical outcomes among adults with persistent symptoms after mild traumatic brain injury (mTBI).

METHODS

Participants with persistent symptoms after mTBI (N=83) completed measures assessing dimensions of insecure attachment (Relationship Scales Questionnaire [RSQ]), persistent symptoms (Rivermead Post-Concussion Symptoms Questionnaire), depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder-7), and health-related quality of life (HRQOL) (Quality of Life After Brain Injury-Overall Scale). Questionnaires were administered at clinic intake (mean=18.1 weeks postinjury) and again 3-4 months later (mean=32.2 weeks postinjury), except the RSQ, which was administered only in the follow-up assessment. Treatment response for each outcome was calculated as the difference between scores at clinic intake and follow-up. Generalized linear models were fitted for each clinical outcome, with RSQ variables as predictors.

RESULTS

Higher attachment anxiety was associated with greater persistent symptom severity, greater depression and anxiety symptoms, and worse HRQOL at follow-up. Higher attachment anxiety was also associated with less improvement in depression and HRQOL over time. In contrast, attachment avoidance was unrelated to any of the clinical outcomes.

CONCLUSIONS

Attachment anxiety, the fear that a significant other will not be available in stressful circumstances, may be a particularly important social factor associated with health among adults with persistent symptoms after mTBI. Greater consideration of the attachment system is warranted in mTBI care and research.

Early Postinjury Screen Time and Concussion Recovery

OBJECTIVES

To determine the association between early screen time (7-10 days postinjury) and postconcussion symptom severity in children and adolescents with concussion, as compared to those with orthopedic injury (OI).

METHODS

This was a planned secondary analysis of a prospective longitudinal cohort study. Participants were 633 children and adolescents with acute concussion and 334 with OI aged 8 to 16, recruited from 5 Canadian pediatric emergency departments. Postconcussion symptoms were measured using the Health and Behavior Inventory at 7 to 10 days, weekly for 3 months, and biweekly from 3 to 6 months postinjury. Screen time was measured by using the Healthy Lifestyle Behavior Questionnaire. Generalized least squares models were fit for 4 Health and Behavior Inventory outcomes (self- and parent-reported cognitive and somatic symptoms), with predictors including screen time, covariates associated with concussion recovery, and 2 3-way interactions (self- and parent-reported screen time with group and time postinjury).

RESULTS

Screen time was a significant but nonlinear moderator of group differences in postconcussion symptom severity for parent-reported somatic (P = .01) and self-reported cognitive symptoms (P = .03). Low and high screen time were both associated with relatively more severe symptoms in the concussion group compared to the OI group during the first 30 days postinjury but not after 30 days. Other risk factors and health behaviors had stronger associations with symptom severity than screen time.

CONCLUSIONS

The association of early screen time with postconcussion symptoms is not linear. Recommending moderation in screen time may be the best approach to clinical management.

Somatization in Adolescents With Persistent Symptoms After Concussion: A Retrospective Chart Review

OBJECTIVE

After concussion, approximately 30% of adolescents experience symptoms that persist beyond 1 month postinjury. For some, these symptoms affect functioning, development, and quality of life. Somatization, where psychological distress contributes to physical symptoms, may contribute to persistent symptoms after concussion in some adolescents. Understanding how clinicians identify somatization in adolescents with persistent symptoms after concussion in practice is a critical next step in improving our understanding, identification, and subsequent treatment of somatization in this patient population. To address this, the investigators assessed and compared characteristics of adolescents with persistent symptoms after concussion with and without clinician-identified somatization.

METHODS

Participants were adolescents (N=94) referred for persistent symptoms after concussion to a specialty youth concussion clinic between January 2016 and May 2018. A retrospective chart review extracted demographic and injury characteristics, symptoms after concussion, school attendance, premorbid experiences, mental health, and medical service use. Participants with physician-identified somatization were compared with those without physician-identified somatization on these measures.

RESULTS

Adolescents with identified somatization had more severe and atypical neurological and psychiatric symptoms after concussion and more postinjury impairment in school attendance, were more likely to have a history of premorbid chronic pain or medically unexplained symptoms, and obtained more neuroimaging and health care after injury compared with those unaffected by somatization. They did not differ in mood or anxiety symptom self-reports.

CONCLUSIONS

This study identified characteristic differences and similarities in adolescents with and without clinician-identified somatization after a prolonged concussion recovery. These findings have the potential to improve clinical identification of somatization in youths following a concussion and may aid in treatment among this demographic group.

Criterion validity of the brief test of adult cognition by telephone (BTACT) for mild traumatic brain injury

OBJECTIVES

There is a growing demand for remote assessment options for measuring cognition after mild traumatic brain injury (mTBI). The current study evaluated the criterion validity of the Brief Test of Adult Cognition by Telephone (BTACT) in distinguishing between adults with mTBI and trauma controls (TC) who sustained injuries not involving the head or neck.

METHODS

The BTACT was administered to the mTBI (n = 46) and TC (n = 35) groups at 1-2 weeks post-injury. Participants also completed the Rivermead Post Concussion Symptoms Questionnaire.

RESULTS

The BTACT global composite score did not significantly differ between the groups (t(79) = -1.04, p = 0.30); the effect size was small (d = 0.23). In receiver operating characteristic curve analyses, the BTACT demonstrated poor accuracy in differentiating between the groups (AUC = 0.567, SE = 0.065, 95% CI [0.44, 0.69]). The BTACT's ability to discriminate between mTBI and TCs did not improve after excluding mTBI participants (n = 15) who denied ongoing cognitive symptoms (AUC = 0.567, SE = 0.072, 95% CI [0.43, 0.71]).

CONCLUSIONS

The BTACT may lack sensitivity to subacute cognitive impairment attributable to mTBI (i.e., not explained by bodily pain, post-traumatic stress, and other nonspecific effects of injury).

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

Background

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

Methods

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

Discussion

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

Trial registration

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

Supplementary Information

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

Effectiveness of a guideline implementation tool for supporting management of mental health complications after mild traumatic brain injury in primary care: protocol for a randomised controlled trial

INTRODUCTION

Mental health problems frequently interfere with recovery from mild traumatic brain injury (mTBI) but are under-recognised and undertreated. Consistent implementation of clinical practice guidelines for proactive detection and treatment of mental health complications after mTBI will require evidence-based knowledge translation strategies. This study aims to determine if a guideline implementation tool can reduce the risk of mental health complications following mTBI. If effective, our guideline implementation tool could be readily scaled up and/or adapted to other healthcare settings.

METHODS AND ANALYSIS

We will conduct a triple-blind cluster randomised trial to evaluate a clinical practice guideline implementation tool designed to support proactive management of mental health complications after mTBI in primary care. We will recruit 535 adults (aged 18-69 years) with mTBI from six emergency departments and two urgent care centres in the Greater Vancouver Area, Canada. Upon enrolment at 2 weeks post-injury, they will complete mental health symptom screening tools and designate a general practitioner (GP) or primary care clinic where they plan to seek follow-up care. Primary care clinics will be randomised into one of two arms. In the guideline implementation tool arm, GPs will receive actionable mental health screening test results tailored to their patient and their patients will receive written education about mental health problems after mTBI and treatment options. In the usual care control arm, GPs and their patients will receive generic information about mTBI. Patient participants will complete outcome measures remotely at 2, 12 and 26 weeks post-injury. The primary outcome is rate of new or worsened mood, anxiety or trauma-related disorder on the Mini International Neuropsychiatric Interview at 26 weeks.

ETHICS AND DISSEMINATION

Study procedures were approved by the University of British Columbia's research ethics board (H20-00562). The primary report for the trial results will be published in a peer-reviewed journal. Our knowledge user team members (patients, GPs, policymakers) will co-create a plan for public dissemination.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT04704037).

Memory for forgetting in adults with persistent symptoms following concussion

INTRODUCTION

Persistent memory complaints following concussion often do not coincide with evidence of objective memory impairment. To the extent this clinical presentation represents Functional Cognitive Disorder (FCD), we would expect preservation or even enhancement of memory for instances of forgetting, based on two lines of prior evidence. First, emotional arousal enhances autobiographical memory. People who experience memory lapses as worrisome may better remember them. Second, individuals with FCD can paradoxically provide detailed accounts of memory lapses compared to patients with neurodegenerative disease, who tend to provide vague examples. The current study aimed to better characterize the recall of forgetting events in people with subjective memory problems following concussion.

METHODS

The study sample consisted of adults with chronic post-concussion symptoms (N = 37, M = 42.7 years old; 70.27% women; M = 24.9 months post-injury) and normal-range performance on conventional neuropsychological tests. Participants completed a measure of memory complaint severity and the Autobiographical Interview (AI). The AI was used to quantify the richness of narrative recollections of recent instances when they forgot something and (control) personal events that did not involve forgetting. Linear regression modeling assessed the relationship between memory complaint severity and AI variables, including narrative details, valence, arousal, and rehearsal of memories.

RESULTS

There was no association between memory complaint severity and memory for forgetting vs. control events. We further found no association between memory complaint severity and AI performance overall (collapsing across forgetting and control events). Participants with greater memory complaints experienced past memory lapses as more negative than control memories, but did not consistently differ on other AI phenomenological variables.

CONCLUSION

Autobiographical recall of memory lapses appears preserved but not selectively heightened in people who report experiencing severe memory problems long after concussion. This inconsistency supports conceptualization of persistent memory complaints after concussion as FCD.

History of Functional Somatic Syndromes and Persistent Symptoms After Mild Traumatic Brain Injury

OBJECTIVE

Somatization is thought to underlie functional somatic syndromes (FSSs) and may also contribute to prolonged symptoms after mild traumatic brain injury (mTBI). The investigators evaluated the prevalence of FSSs in patients seeking specialty care after mTBI and whether a history of FSSs was associated with symptom persistence.

METHODS

A total of 142 patients with mTBI completed questionnaires regarding demographic information, injury characteristics, and medical history, including history of diagnosed FSSs at clinic intake (mean=41 days postinjury [SD=22.41]). Postconcussion symptoms were assessed at clinic intake and again 1 and 3 months later. A linear mixed-effects model was used to determine whether history of FSSs was related to persistent mTBI symptoms over time.

RESULTS

A history of at least one FSS was reported by 20.4% of patients. In the linear mixed model, postconcussion symptom scores were not significantly different over time among patients with a history of one or more FSSs or two or more FSSs from those with no FSSs. A history of one or more FSSs or two or more FSSs (versus no FSS) was not associated with increased odds of severe postconcussion symptoms at clinic intake (one or more FSSs: odds ratio=0.88, 95% CI=0.38-2.03; two or more FSSs: odds ratio=1.78, 95% CI=0.45-7.03), at the 1-month follow-up visit (one or more FSSs: odds ratio=0.57, 95% CI=0.22-1.45; two or more FSSs: odds ratio=0.57, 95% CI=0.14-2.37), or at the 3-month follow-up visit (one or more FSSs: odds ratio=0.97, 95% CI=0.36-2.63; two or more FSSs: odds ratio=1.27, 95% CI=0.29-5.65).

CONCLUSIONS

In this sample, the prevalence rates of FSSs were higher than rates previously reported for the general population. However, FSS history did not predict higher postconcussion symptom burden at clinic intake or persistence over the following 3 months. Further research is needed to clarify the potential role of somatization in poor mTBI outcome.

Perceptions of Symptom Duration are Associated With Emotional Distress and Functioning in Adolescents With Protracted Concussion Recovery

 

Adolescents with persisting post-concussive symptoms often report high levels of emotional distress, which can impact their daily functioning. The associations between modifiable factors, such as perceptions of recovery, and emotional distress have not been investigated in this age group.

Objective

To evaluate perceptions about recovery duration (e.g., “my symptoms will last a long time”, “my symptoms will be permanent rather than temporary”) and its associations with emotional distress and functioning in children and adolescents with a slower post-concussive recovery.

Methods

Participants (N = 49, 69% girls, 11–17 years old, M = 15.8 years old, SD = 1.8) were recruited from a concussion clinic on average 7.7 months after injury (SD = 2.5). Measures included the Illness Perception Questionnaire Revised (perceived duration of symptoms only) to evaluate recovery expectations, the Health and Behavior Inventory (self and parent reports) to evaluate current post-concussive symptoms (cognitive and somatic symptoms), the emotional distress subscale of the Strengths and Difficulties Questionnaire (SDQ—self-report), and the emotional functioning subscale of the Pediatric Quality of Life Questionnaire (PedsQL—self-report).

Results

Regression analyses (linear models with all covariates entered at once) suggested that greater expectations for symptom persistence were significantly associated with higher emotional distress on both SDQ and PedsQL subscales, after controlling for post-concussive symptom severity and other confounds. Emotional distress/functioning was not associated with perceptions of symptom duration reported by parents, severity of post-concussive symptoms (self- and parent reports), age, number of concussions, time since injury, or a history of mental health concern or diagnosis (parent-reported).

Conclusions

This study suggests that pessimistic attitudes for recovery duration may be more strongly associated with emotional distress than current post-concussive symptom severity or a history of mental health concern or diagnosis.

Sleep Insufficiency and Baseline Preseason Concussion-Like Symptom Reporting in Youth Athletes

OBJECTIVE

To examine the association between insufficient sleep and baseline symptom reporting in healthy student athletes.

DESIGN

Cross-sectional cohort study.

SETTING

Preseason testing for student athletes.

PARTICIPANTS

Student athletes (n = 19 529) aged 13 to 19 years who completed the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), including the number of hours slept the night before, and denied having developmental/health conditions, a concussion in the past 6 months, and a previous history of 2 or more concussions.

INDEPENDENT VARIABLES

Total hours of sleep the night before testing (grouped by ≤5, 5.5-6.5, 7-8.5, and ≥9 hours), gender, and concussion history.

MAIN OUTCOME MEASURES

Symptom burden on the Post-Concussion Symptom Scale (modified to exclude sleep-related items), cognitive composite scores, and prevalence of athletes who reported a symptom burden resembling the International Classification of Diseases, 10th Revision (ICD-10) diagnosis of postconcussional syndrome (PCS).

RESULTS

Fewer hours of sleep, gender (ie, girls), and 1 previous concussion (vs 0) were each significantly associated with higher total symptom scores in a multivariable model (F = 142.01, P < 0.001, R2 = 0.04). When a gender-by-sleep interaction term was included, the relationship between sleep and symptoms was stronger for girls compared with boys. In healthy athletes who slept ≤5 hours, 46% of girls and 31% of boys met the criteria for ICD-10 PCS compared with 16% of girls and 11% of boys who slept ≥9 hours. Sleep duration was not meaningfully associated with neurocognitive performance.

CONCLUSIONS

Insufficient sleep the night before testing is an important factor to consider when interpreting symptom reporting, especially for girls. It will be helpful for clinicians to take this into account when interpreting both baseline and postinjury symptom reporting.

OUP accepted manuscript

OBJECTIVE

The etiology of persistent memory complaints after concussion is poorly understood. Memory perfectionism (highly valuing memory ability and intolerance of minor memory lapses) may help explain why some people report persistent subjective memory problems in the absence of corresponding objective memory impairment. This study investigated the relationship between memory perfectionism and persistent memory complaints after concussion.

METHODS

Secondary analysis of baseline data from a randomized controlled trial. Adults (N = 77; 61% women) with persistent symptoms following concussion were recruited from outpatient specialty clinics. Participants completed the National Institutes of Health Toolbox Cognition Battery, Test of Memory Malingering-Trial 1, and questionnaires measuring memory perfectionism (Metamemory in Adulthood-Achievement subscale), forgetfulness and other postconcussion symptoms (Rivermead Postconcussion Symptoms Questionnaire; RPQ), and depression (Patient Health Questionnaire-2) at M = 17.8 weeks postinjury. Patients with versus without severe memory complaints (based on the RPQ) were compared.

RESULTS

Memory perfectionism was associated cross-sectionally with severe memory complaint, after controlling for objective memory ability, overall cognitive ability, and depression (95% confidence interval for odds ratio = 1.11-1.40). Sensitivity analyses showed that this relationship did not depend on use of specific objective memory tests nor on inclusion of participants who failed performance validity testing. In a control comparison to test the specificity of identified relationships, memory perfectionism was not associated with severe fatigue (95% confidence interval for odds ratio = 0.91-1.07).

CONCLUSIONS

Memory perfectionism may be a risk factor for persistent memory symptoms after concussion, with potential relevance to the spectrum of functional cognitive disorders more broadly.

Feasibility of concussion rehabilitation approaches tailored to psychological coping styles: A randomized controlled trial

OBJECTIVE

To evaluate the feasibility of a clinical trial involving participants with concussion randomized to treatments designed to address fear avoidance or endurance coping, which are risk factors for disability. A secondary objective was to evaluate whether each treatment could effect selective change on targeted coping outcomes.

DESIGN

Randomized controlled trial.

SETTING

Outpatient concussion clinics.

PARTICIPANTS

73 adults (M=42.5 years old) who had persistent post-concussion symptoms and high avoidance or endurance behavior were enrolled at M=12.9 weeks post injury. 10 participants did not complete treatment.

INTERVENTIONS

Participants were randomized to an interdisciplinary rehabilitation program delivered via videoconferencing and tailored to avoidance coping (graded exposure therapy; GET) or endurance coping (operant condition-based pacing strategies plus mindfulness training; Pacing+).

MAIN OUTCOME MEASURES

Feasibility outcomes included screening efficiency, accrual, credibility, treatment fidelity, adherence, and retention. Avoidance was measured with the Fear Avoidance Behavior after Traumatic Brain Injury questionnaire and endurance behavior with the Behavioral Response to Illness Questionnaire.

RESULTS

Screening efficiency, or the proportion of clinic patients who were assessed for eligibility, was 44.5% (275/618). 65.8% (73/111) of eligible patients were randomized (n=37 to GET and n=36 to Pacing+), meeting accrual targets. 91.7% (55/60) of participants perceived treatment as credible. Therapists covered M=96.8% of essential prescribed elements, indicating excellent fidelity. The majority (71.2%; 47/66) of participants consistently attended treatment sessions and completed between-session homework. Retention was strong, with 65 of 73 (89%) randomized participants completing the outcome assessment. GET was associated with greater post-treatment reductions in avoidance behavior compared to Pacing+ (Cohen's d_{repeated measures} = 0.81), whereas the treatment approach-specific effect of Pacing+ on endurance behavior was less pronounced (Cohen's d_{repeated measures} = 0.39).

CONCLUSIONS

Findings support a future efficacy-focused clinical trial. GET has the potential to selectively reduce fear avoidance behavior after concussion, and, via this mechanism, to prevent or reduce disability.

Unexpected symptoms after concussion: Potential links to functional neurological and somatic symptom disorders

OBJECTIVE

Reporting of unexpected symptoms after concussion might, in some people, reflect a Functional Neurological Disorder (FND), Somatic Symptom Disorder (SSD), or exaggeration (feigning). This study aimed to determine whether reporting unexpected symptoms after concussion was associated with risk factors for FND/SSD, exaggeration, or both.

METHOD

Adults with persistent symptoms following concussion (N = 77; 61% women) rated the presence and severity of unexpected neurological symptoms (from the Screening for Somatoform Symptoms scale, e.g., paralysis) and somatic symptoms (from the Patient Health Questionnaire-15, e.g., stomach pain) that did not overlap with post-concussion symptom scale items. The independent variables were risk factors for exaggeration (neuropsychological performance validity test failure and personal injury litigation) and predisposing and perpetuating factors for developing FND and/or SSD (e.g., fear avoidance behavior).

RESULTS

When adjusting for all covariates, fear avoidance behavior was most strongly related to unexpected neurological symptoms (B = 0.11, 95% confidence interval = 0.05-0.18, p < .001), while current anxiety scores were most strongly related to unexpected somatic symptoms (B = 0.34, 95% confidence interval = 0.15-0.52, p < .001). Performance validity test failure and litigation were not significant predictors in either model.

CONCLUSION

Unexpected neurological and other somatic symptoms after concussion should not be dismissed as exaggeration. Psychological factors thought to perpetuate FND and SSD (e.g., fear avoidance behavior) may contribute to unexpected symptoms following concussion. More research is needed at the intersection of FND, SSD, and persistent post-concussive symptoms.

Psychological mediators of avoidance and endurance behavior after concussion

OBJECTIVE

The avoidance-endurance model (AEM) proposes multiple pathways from acute to chronic pain, with distinct cognitive and behavioral components in each pathway. The AEM may also be applicable to persistent symptoms after concussion. In this study, we tested the AEM as an explanatory framework for concussion outcomes, by using mediation analyses through the proposed psychological mechanisms. Based on the AEM, we hypothesized that postconcussion symptoms would significantly predict avoidance behavior through catastrophizing, and endurance behavior through thought suppression and self-distraction.

PARTICIPANTS AND METHODS

We recruited 84 adults seeking treatment at 2 outpatient concussion clinics (M = 41.8 years old, 63% female) who completed measures of postconcussion symptoms, catastrophizing, thought suppression, "self-distraction" (Five Factor Mindfulness Questionnaire "Act with Awareness" Scale reverse-scored), avoidance behavior, and endurance behavior at an average of 17.8 weeks postconcussion. We conducted 3 mediation analyses to assess each of the AEM pathways.

RESULTS

We found a significant indirect effect of postconcussion symptoms on avoidance behavior through catastrophizing (ab = .113 (.036), 95% CI [.053, .195]). The indirect effects of postconcussion symptoms on endurance behavior through thought suppression (ab = .011 (.012), 90% CI [.002, .035]) and "self-distraction" (ab = .003 (.009), 90% CI [.008, .022]) were not statistically significant.

CONCLUSIONS

Results supported the catastrophizing-avoidance pathway in concussion, but not the thought-suppression-endurance or self-distraction-endurance pathways. Therefore, catastrophic thinking about concussion symptoms may be an appropriate treatment target for individuals who exhibit fear-avoidance behavior. Further research is needed to establish whether thought suppression and self-distraction are relevant for interventions aimed at reducing excessive endurance behavior. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Normative Data for the Fear Avoidance Behavior After Traumatic Brain Injury Questionnaire in a Clinical Sample of Adults With Mild TBI

OBJECTIVE

Fear avoidance behavior after a concussion or mild traumatic brain injury (mTBI) is associated with a number of adverse outcomes, such as higher symptom burden, emotional distress, and disability. The Fear Avoidance Behavior after Traumatic Brain Injury Questionnaire (FAB-TBI) is a recently developed and validated self-report measure of fear avoidance after mTBI. The objective of this study was to derive clinical normative data for the FAB-TBI. To determine whether demographic stratification was necessary and to further support clinical interpretation, we also explored associations between fear avoidance behavior and demographic and injury variables.

SETTING

Five concussion clinics in Canada.

PARTICIPANTS

Adults who sustained an mTBI (N = 563).

DESIGN

Cross-sectional.

MAIN MEASURES

Participants completed the Fear Avoidance Behavior after Traumatic Brain Injury Questionnaire (FAB-TBI) and measures of postconcussion symptom burden (Rivermead Postconcussion Symptoms Questionnaire, Sport Concussion Assessment Tool-5) at clinic intake.

RESULTS

Generalized linear modeling revealed that females reported more fear avoidance than males (95% CI = 0.66 to 2.75), indicating that FAB-TBI normative data should be stratified by sex. Differences between recruitment sites on FAB-TBI scores were reduced but not eliminated by controlling for potential confounds. Loss of consciousness (95% CI =0.61 to 2.76) and higher postconcussion symptom burden (95% CI = 0.79 to 1.03) were also associated with higher FAB-TBI scores, but time since injury was not (95% = CI -0.4 to 0.03). Tables to convert FAB-TBI raw scores to Rasch scores to percentiles are presented.

CONCLUSION

These findings support clinical interpretation of the FAB-TBI and further study of fear avoidance after mTBI.

Barriers and facilitators to the management of mental health complications after mild traumatic brain injury

Background:

Clinical practice guidelines for mild traumatic brain injury (mTBI) management call on family physicians to proactively screen and initiate treatment for mental health complications, but evidence suggests that this does not happen consistently. The authors aimed to identify physician-perceived barriers and facilitators to early management of mental health complications following mTBI.

Methods & results:

Semi-structured interviews based on the Theoretical Domains Framework (TDF) were conducted with 11 family physicians. Interview transcripts were analyzed using directed content analysis. Factors influencing management of mental health post-mTBI were identified along five TDF domains.

Conclusion:

Family physicians could benefit from accessible and easily implemented resources to manage post-mTBI mental health conditions, having a better defined role in this process, and formalization of referrals to mental health specialists.

Best practice recommendations call for family doctors to proactively screen for and treat mental health problems that might arise after a mild traumatic brain injury (mTBI) (also known as a concussion). However, previous studies show that these recommendations are not followed consistently. The authors aimed to find reasons why this is not happening by interviewing 11 family doctors. The authors found that family doctors are mostly unaware of resources to guide their practice, are unsure about their role in mental health management, and experience difficulties in referring their patients to specialists for mental health care. Actively providing family doctors with knowledge and tools that help them initiate mental health care, as well as a structure for mental health referrals after mild traumatic brain injury, would help doctors apply best practice recommendations.

Telehealth coaching to improve self-management for secondary prevention after stroke: A randomized controlled trial of Stroke Coach

BACKGROUND

Stroke Coach is a lifestyle coaching telehealth program to improve self-management of stroke risk factors.

AIMS

To examine the efficacy of Stroke Coach on lifestyle behavior and risk factor control among community-living stroke survivors within one-year post stroke.

METHODS

Participants were randomized to Stroke Coach or an attention control Memory Training group. Lifestyle behavior was measured using the Health Promoting Lifestyle Profile II. Secondary outcomes included specific behavioral and cardiometabolic risk factors, health-related quality of life (HRQoL), cognitive status, and depressive symptoms. Measurements were taken at baseline, post-intervention (6 months), and retention (12 month). Linear mixed-effects models were used to test the study hypotheses (p < 0.05). All analyses were intention-to-treat.

RESULTS

The mean age of the Stroke Coach (n = 64) and Memory Training (n = 62) groups was 67.2 and 69.1 years, respectively. The majority of participants (n = 100) had mild stroke (modified Rankin Scale = 1 or 2), were active, with controlled blood pressure (mean = 129/79 mmHg) at baseline. At post-intervention, there were no significant differences in lifestyle (b = -2.87; 95%CI - 8.03 to 2.29; p = 0.28). Glucose control, as measured by HbA1c (b = 0.17; 95%CI 0.17 to 0.32; p = 0.03), and HRQoL, measured using SF-36 Physical Component Summary (b = -3.05; 95%CI -5.88 to -0.21; p = 0.04), were significantly improved in Stroke Coach compared to Memory Training, and the improvements were maintained at retention.

CONCLUSION

Stroke Coach did not improve lifestyle behavior; however, there were improvements to HbA1c and HRQoL among community-living stroke survivors with mild stroke-related disability. (ClinicalTrials.gov identifier: NCT02207023).

Fear avoidance behavior in youth with poor recovery from concussion: measurement properties and correlates of a new scale

The objective of the current study was to develop a measure of fear avoidance behavior after concussion for youth and parent respondents and examine its basic psychometric properties and correlates. Children (N = 51) who were seen in a hospital concussion clinic after sustaining a concussion (M = 7.6 months, SD = 7.01) and their primary caregiver (N = 51)completed self- and informant-report measures of fear avoidance (Pediatric Fear Avoidance Behavior after Traumatic Brain Injury Questionnaire; PFAB-TBI), post-concussion symptoms (Health Behavior Inventory), emotional distress (Strengths and Difficulties Questionnaire), and quality of life (Pediatric Quality of Life Inventory Version 4.0). The self- and informant-report PFAB-TBI scores were moderately correlated (r = 0.51, p < 0.001). Neither measure demonstrated floor or ceiling effects. Both had strong internal consistency (Cronbach's α = 0.87 and 0.89, respectively). The PFAB-TBI self-report was positively correlated with somatic symptoms (r = 0.37), emotional distress (r = 0.39), and negatively associated with quality of life (r = -0.57). The PFAB-TBI informant-report was positively associated with informant reported somatic symptoms (r = 0.52) and emotional distress (r = .50) Overall, the PFAB-TBI has desirable basic measurement properties and expected correlations with clinical outcomes. This measure can potentially help clinicians and researchers better understand the impacts of fear avoidance behavior after pediatric concussion.

De-implementing Prolonged Rest Advice for Concussion in Primary Care Settings: A Pilot Stepped Wedge Cluster Randomized Trial

OBJECTIVE

To evaluate the feasibility and preliminary efficacy of a de-implementation intervention to support return-to-activity guideline use after concussion.

SETTING

Community.

PARTICIPANTS

Family physicians in community practice (n = 21 at 5 clinics).

DESIGN

Pilot stepped wedge cluster randomized trial with qualitative interviews. Training on new guidelines for return to activity after concussion was provided in education outreach visits.

MAIN MEASURES

The primary feasibility outcomes were recruitment, retention, and postencounter form completion (physicians prospectively recorded what they did for each new patient with concussion). Efficacy indicators included a knowledge test and guideline compliance based on postencounter form data. Qualitative interviews covered Theoretical Domains Framework elements.

RESULTS

Recruitment, retention, and postencounter form completion rates all fell below feasibility benchmarks. Family physicians demonstrated increased knowledge about the return-to-activity guideline (M = 8.8 true-false items correct out of 10 after vs 6.3 before) and improved guideline adherence (86% after vs 25% before) after the training. Qualitative interviews revealed important barriers (eg, beliefs about contraindications) and facilitators (eg, patient handouts) to behavior change.

CONCLUSIONS

Education outreach visits might facilitate de-implementation of prolonged rest advice after concussion, but methodological changes will be necessary to improve the feasibility of a larger trial. The qualitative findings highlight opportunities for refining the intervention.

A Live Video Mind-Body Treatment to Prevent Persistent Symptoms Following Mild Traumatic Brain Injury: Protocol for a Mixed Methods Study

Background

Every year, approximately 42 million people sustain a mild traumatic brain injury (mTBI, also known as concussion), with particularly high rates among college-aged individuals. A substantial proportion of these people (44%-64%) develop persistent symptoms that are challenging to treat, costly, and associated with significant disability. Anxiety has emerged as a risk factor for progression from acute to persistent mTBI symptoms.

Objective

This study aims to develop, adapt, and establish the feasibility of the Toolkit for Optimal Recovery after Concussions (TOR-C), an innovative mind-body program aimed at preventing persistent symptoms among young adults with mTBI and comorbid anxiety. Here, we describe the proposed study design, methodology, measurement, and treatment manuals.

Methods

In phase 1, we will conduct individual, live video qualitative interviews (up to n=20) with college-aged individuals with mTBI and comorbid anxiety to inform adaptation of the intervention and study procedures. In phase 2, an open pilot of the live video TOR-C (n=5) with exit interviews will be conducted to explore the initial feasibility, acceptability, and credibility of the program and to refine the study procedures. Phase 3 will involve conducting a feasibility randomized controlled trial (N=50) of the TOR-C versus a health education control (Health Enhancement for Concussions; HE-C), both delivered via live video, to establish feasibility of recruitment procedures (screening, eligibility, and enrollment) and data collection; feasibility, credibility, and acceptability of the live video TOR-C and HE-C (adherence, retention, fidelity, and satisfaction) following prespecified benchmarks; and a signal of improvement in outcomes.

Results

Phase 1 of the study has been approved by the Massachusetts General Hospital Institutional Review Board. Study completion is anticipated by early 2025.

Conclusions

We will develop and test the first mind-body intervention focused on prevention of persistent symptoms following mTBI in young adults with comorbid anxiety problems. This will allow us to establish feasibility markers in postconcussive symptoms, anxiety, disability, and fear avoidance to inform a future efficacy trial of the TOR-C versus HE-C.

International Registered Report Identifier (IRRID)

PRR1-10.2196/25746

Avoidance and endurance coping after mild traumatic brain injury are associated with disability outcomes

Objective: Fear-avoidance and endurance behavior are well-established maladaptive coping styles in several chronic health conditions. There is also emerging evidence that both fear-avoidance and endurance coping are associated with poor outcome from mild traumatic brain injury (mTBI). The current study sought to characterize the early trajectories of avoidance and endurance behavior and confirm their association with disability outcomes. Method: Adults with mTBI (N = 88) completed measures of avoidance, endurance, and postconcussive symptoms at clinic intake (M = 40.2 days since injury). Avoidance and endurance measures were readministered 1 month later (N = 79), and a measure of perceived functional disability (World Health Organization Disability Assessment Schedule 2.0) was completed 3 months after clinic intake (N = 69). Results: Avoidance and endurance coping were weakly positively correlated with each other at intake (r = .28) and at 1 month postintake (r = .28). Change scores on these two measures over time were not significantly correlated (r = .04). Avoidance coping tended to decrease over time (95% CI [0.6, 2.5]; p = .002), whereas changes in endurance coping were variable. In generalized linear modeling, higher avoidance and endurance at clinic intake and increasing (or less rapidly decreasing) levels of these coping styles over 1 month was associated with greater perceived disability ratings at 3 months, even after controlling for postconcussion symptom severity at intake. Conclusion: These findings suggest that avoidance and endurance behavior are distinct coping styles with unique trajectories during the subacute recovery period. The results also support the need for psychologically informed early interventions that target specific profiles of maladaptive coping to mitigate risk for poor outcomes post-mTBI. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Examining Test-Retest Reliability and Reliable Change for Cognition Endpoints for the CENTER-TBI Neuropsychological Test Battery

Objective: Seven candidate cognition composite scores have been developed and evaluated as part of a research program designed to validate a cognition endpoint for traumatic brain injury (TBI) research and clinical trials, but these composites have yet to be examined longitudinally. This study examined test-retest reliability and methods for determining reliable change for these seven candidate composite scores, using the neuropsychological test battery from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI).

Methods: Participants (18–59 years-old) with mild TBI (n = 124), orthopedic trauma without head injury (n = 67), and healthy community controls (n = 63) from the Trondheim MTBI follow-up study completed the CENTER-TBI neuropsychological test battery at 2 weeks and 3 months after injury. The battery included both traditional paper-and-pencil tests and computerized tests from the Cambridge Neuropsychological Test Automated Battery (CANTAB). Seven composite scores were calculated for the paper-and-pencil tests, the CANTAB tests, and all tests combined (i.e., 21 composites in total on each assessment): the overall test battery mean (OTBM); global deficit score (GDS); neuropsychological deficit score-weighted (NDS-W); low score composite (LSC); and the number of scores ≤5th percentile, ≤16th percentile, or <50th percentile. The OTBM was calculated by averaging T scores for all tests. The other composite scores were deficit-based scores, assigning different weights to low scores.

Results: All composites revealed better cognitive performance at the 3-month assessment compared to the 2-week assessment and the magnitude of improvement was similar across groups. Differences, in terms of effect sizes, were largest on the OTBMs. In the combined composites, the test-retest correlation was highest for the OTBM (Spearman's rho = 0.87, in the community control group) and lowest for the number of scores ≤5th percentile (rho = 0.41).

Conclusion: The high test-retest reliability of the OTBM appears to favor its use in TBI research; however, future studies are needed to examine these candidate composite scores in participants with more severe TBIs and cognitive deficits and the association of the composites with functional outcomes.

Promoting early treatment for mild traumatic brain injury in primary care with a guideline implementation tool: a pilot cluster randomised trial

OBJECTIVES

New clinical practice guidelines for the management of mild traumatic brain injury (mTBI) emphasise that family physicians should proactively screen and initiate treatment for depression/anxiety, insomnia and headaches. This study aimed to evaluate the feasibility of delivering an implementation intervention to family physicians.

DESIGN

Pilot cluster randomised controlled trial.

SETTING

Specialty outpatient clinic (recruitment) and primary care (implementation).

PARTICIPANTS

114 primary care clinics were randomised. These clinics were associated with 137 unique family physicians caring for 148 adult patients who sustained an mTBI within the previous 3 months and were seeking care for persistent symptoms.

INTERVENTIONS

Patients completed self-report screening measures for depression/anxiety, insomnia and headaches. A tailored letter that incorporates the patient's screening test results and associated treatment algorithms was sent to their family physician (or walk-in clinic). Physicians at clinics assigned to the control condition received a generic letter, without the screening test results.

PRIMARY OUTCOME MEASURES

Feasibility outcomes included the frequency of primary care follow-up, retention rates and reliability of patient recall of their physicians' actions (primary mechanistic outcome). The primary efficacy outcome was the Rivermead Post-Concussion Symptom Questionnaire (RPQ).

RESULTS

Most patients (97.8%; 128 of 131) followed up at the primary care clinic they planned to. Retention rates were 88% (131 of 148) and 78% (116 of 148) at the 1-month and 3-month assessments, respectively. Agreement between patient recall of their physicians' actions and medical chart audits was moderate (intraclass correlation coefficient=0.48-0.65). Patients in the experimental group reported fewer symptoms on the RPQ compared with those in the control group, whose physician received a general letter (B=-4.0, 95% CI: -7.3 to -0.7).

CONCLUSIONS

A larger trial will need to address minor feasibility challenges to evaluate the effectiveness of this guideline implementation tool for improving mTBI clinical outcomes and confirm the mechanism(s) of intervention benefit.

TRIAL REGISTRATION NUMBER

NCT03221218.