A recently published review of 45 studies concluded that approximately half of individuals who sustain a single mild traumatic brain injury (MTBI) experience long-term cognitive impairment (McInnes ...et al. Mild Traumatic Brain Injury (mTBI) and chronic cognitive impairment: A scoping review. PLoS ONE 2017;12:e0174847). Stratified by age, they reported that 50% of children and 58% of adults showed some form of cognitive impairment. We contend that the McInnes et al. review used a definition of "cognitive impairment" that was idiosyncratic, not applicable to individual patients or subjects, inconsistent with how cognitive impairment is defined in clinical practice and research, and resulted in a large number of false positive cases of cognitive impairment. For example, if a study reported a statistically significant difference on a single cognitive test, the authors concluded that every subject with a MTBI in that study was cognitively impaired-an approach that cannot be justified statistically or psychometrically. The authors concluded that impairment was present in various cognitive domains, such as attention, memory, and executive functioning, but they did not analyze or report the results from any of these specific cognitive domains. Moreover, their analyses and conclusions regarding many published studies contradicted the interpretations provided by the original authors of those studies. We re-reviewed all 45 studies and extracted the main conclusions from each. We conclude that a single MTBI is not associated with a high incidence of chronic cognitive impairment.
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Mild Traumatic Brain Injury in 2019-2020 Silverberg, Noah D; Duhaime, Ann-Christine; Iaccarino, Mary Alexis
JAMA : the journal of the American Medical Association,
01/2020, Volume:
323, Issue:
2
Journal Article
Peer reviewed
This JAMA Insights Clinical Update reviews current practice for managing mild traumatic brain injury, which includes monitoring symptom resolution, counseling on return to activity, and timely ...specialty referral.
Practice guidelines universally recommend an initial period of rest for people who sustain a sports-related concussion or mild traumatic brain injury (MTBI) in daily life or military service. This ...practice is difficult to reconcile with the compelling evidence that other health conditions can be worsened by inactivity and improved by early mobilization and exercise. We review the scientific basis for the recommendation to rest after MTBI, the challenges and potential unintended negative consequences of implementing it, and how patient management could be improved by refining it. The best available evidence suggests that complete rest exceeding 3 days is probably not helpful, gradual resumption of preinjury activities should begin as soon as tolerated (with the exception of activities that have a high MTBI exposure risk), and supervised exercise may benefit patients with persistent symptoms.
Depression is a common complication of traumatic brain injury (TBI). New evidence suggests that antidepressant medication may be no more effective than placebo in this population.
Selective serotonin ...reuptake inhibitors are recommended as first-line treatment for depression in contemporary expert consensus clinical practice guidelines for management of TBI. This recommendation is based on multiple prior meta-analyses of clinical trials in depression after TBI as well as depression in the general population. The evidence is mixed. A recent clinical trial and new meta-analysis including that trial found no benefit of antidepressants for depression following TBI. We argue that this finding should not change practice, i.e., patients who present with depression after TBI should still be considered for antidepressant treatment, because they may (1) benefit from robust placebo effects, (2) benefit from an alternative or adjunctive medication if the agent prescribed first does not achieve a depression remission, and (3) make improvements that are not captured well by traditional depression outcome measures, which are confounded by TBI sequelae. Patients with mild TBI are especially appropriate for antidepressant therapy because they, on average, more closely resemble patients with no known TBI history enrolled in typical primary Major Depressive Disorder clinical trials than patients enrolled in TBI trials in placebo-controlled trials published to date.
TBI, and especially mild TBI, is not a contraindication for antidepressant therapy. Health providers should routinely screen and initiate treatment for depression after TBI.
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IMPORTANCE: Every state in the United States has passed legislation for sport-related concussion, making this health issue important for physicians and other health care professionals. Safely ...returning athletes to sport after concussion relies on accurately determining when their symptoms resolve. OBJECTIVE: To evaluate baseline concussion-like symptom reporting in uninjured adolescent student athletes. DESIGN, SETTING, AND PARTICIPANTS: In this cross-sectional, observational study, we studied 31 958 high school athletes from Maine with no concussion in the past 6 months who completed a preseason baseline testing program between 2009 and 2013. RESULTS: Symptom reporting was more common in girls than boys. Most students with preexisting conditions reported one or more symptoms (60%-82% of boys and 73%-97% of girls). Nineteen percent of boys and 28% of girls reported having a symptom burden resembling an International Classification of Diseases, 10th Revision (ICD-10) diagnosis of postconcussional syndrome (PCS). Students with preexisting conditions were even more likely to endorse a symptom burden that resembled PCS (21%-47% for boys and 33%-72% for girls). Prior treatment of a psychiatric condition was the strongest independent predictor for symptom reporting in boys, followed by a history of migraines. For girls, the strongest independent predictors were prior treatment of a psychiatric condition or substance abuse and attention-deficit/hyperactivity disorder. The weakest independent predictor of symptoms for both sexes was history of prior concussions. CONCLUSIONS AND RELEVANCE: In the absence of a recent concussion, symptom reporting is related to sex and preexisting conditions. Consideration of sex and preexisting health conditions can help prevent misinterpretation of symptoms in student athletes who sustain a concussion.
At least 3 million Americans sustain a mild traumatic brain injury (mTBI) each year, and 1 in 5 have symptoms that persist beyond 1 month. Standards of mTBI care have evolved rapidly, with numerous ...expert consensus statements and clinical practice guidelines published in the last 5 years. This Special Communication synthesizes recent expert consensus statements and evidenced-based clinical practice guidelines for civilians, athletes, military, and pediatric populations for clinicians practicing outside of specialty mTBI clinics, including primary care providers. The article offers guidance on key clinical decisions in mTBI care and highlights priority interventions that can be initiated in primary care to prevent chronicity.
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.
Summary
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.
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In his seminal article, Physiogenesis and Psychogenesis in the 'Post-Concussional Syndrome,' Lishman (1988) proposed that neurobiological factors account for the development of the post-concussion ...syndrome and psychological factors become primarily responsible for maintaining it in the chronic phase. Over the 20 years that followed, researchers have advanced our understanding of the etiology of the post-concussion syndrome. Our review of this evidence suggests that neurobiological and psychological factors play a causal role in post-concussion symptoms from the outset, and thus, Lishman's causal model should be updated. If we can clinically identify individuals on a trajectory of poor recovery in the acute post-injury stage, then we can direct secondary prevention towards modifiable risk factors.
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Recent expert agreement statements and evidence-based practice guidelines for mild traumatic brain injury (mTBI) management no longer support advising patients to "rest until asymptomatic," and ...instead recommend gradual return to activity after 1-2 days of rest. The present study aimed to: (i) document the current state of de-implementation of prolonged rest advice, (ii) identify patient characteristics associated with receiving this advice, and (iii) examine the relationship between exposure to this advice and clinical outcomes.
In a case-control design, participants were prospectively recruited from two concussion clinics in Canada's public health care system. They completed self-report measures at clinic intake (Rivermead Post-concussion Symptom Questionnaire, Personal Health Questionnaire-9, and Generalized Anxiety Disorder-7) as well as a questionnaire with patient, injury, and recovery characteristics and the question: "Were you advised by at least one health professional to rest for more than 2 days after your injury?"
Of the eligible participants (
= 146), 82.9% reported being advised to rest for more than 2 days (exposure group). This advice was not associated with patient characteristics, including gender (95% CI odds ratio = 0.48-2.91), race (0.87-6.28) age (0.93-1.01), a history of prior mTBI(s) (0.21-1.20), or psychiatric problems (0.40-2.30), loss of consciousness (0.23-2.10), or access to financial compensation (0.50-2.92). In generalized linear modeling, exposure to prolonged rest advice predicted return to productivity status at intake (B = -1.06, chi-squared(1) = 5.28,
= 0.02; 64.5% in the exposure group vs. 40.0% in the control were on leave from work/school at the time of clinic intake, 19.8 vs. 24% had partially returned, and 11.6 vs. 24% had fully returned to work/school). The exposure group had marginally (non-significantly) higher post-concussion, depression, and anxiety symptoms.
mTBI patients continue to be told to rest for longer than expert recommendations and practice guidelines. This study supports growing evidence that prolonged rest after mTBI is generally unhelpful, as patients in the exposure group were less likely to have resumed work/school at 1-2 months post-injury. We could not identify patient characteristics associated with getting prolonged rest advice. Further exploration of who gets told to rest and who delivers the advice could inform strategic de-implementation of this clinical practice.
Prognostic models can guide clinical management and increase statistical power in clinical trials. The availability and adequacy of prognostic models for mild traumatic brain injury (MTBI) is ...uncertain. The present study aimed to (1) identify and evaluate multivariable prognostic models for MTBI, and (2) determine which pre-, peri-, and early post-injury variables have independent prognostic value in the context of multivariable models. An electronic search of MEDLINE, PsycINFO, PubMed, EMBASE, and CINAHL databases for English-language MTBI cohort studies from 1970-2013 was supplemented by Web of Science citation and hand searching. This search strategy identified 7789 articles after removing duplicates. Of 182 full-text articles reviewed, 26 met eligibility criteria including (1) prospective inception cohort design, (2) prognostic information collected within 1 month post-injury, and (3) 2+variables combined to predict clinical outcome (e.g., post-concussion syndrome) at least 1 month later. Independent reviewers extracted sample characteristics, study design features, clinical outcome variables, predictor selection methods, and prognostic model discrimination, calibration, and cross-validation. These data elements were synthesized qualitatively. The present review found no multivariable prognostic model that adequately predicts individual patient outcomes from MTBI. Suboptimal methodology limits their reproducibility and clinical usefulness. The most robust prognostic factors in the context of multivariable models were pre-injury mental health and early post-injury neuropsychological functioning. Women and adults with early post-injury anxiety also have worse prognoses. Relative to these factors, the severity of MTBI had little long-term prognostic value. Future prognostic studies should consider a broad range of biopsychosocial predictors in large inception cohorts.
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