Concussion Research Articles

Changes in cognitive functional performance and basic activities of daily living in patients with traumatic brain injury after two methods of cognitive retraining

Introduction: Evidence supports a bottom-up approach to assist in addressing functional cognitive deficits in patients with traumatic brain injury (TBI). There is however, little evidence supporting the use of online programmes for this purpose. The aim of this research was to describe the outcomes for cognitive functional performance and basic activities of daily living (bADL) or self-care functioning after cognitive retraining using an online programme versus task-oriented intervention for patients with acute mild and moderate traumatic brain injury (TBIs). Methods: A quantitative, quasi experimental, longitudinal research design was used for determining within-group and between-groups changes for cognitive functional performance and bADL functioning in two sample groups with mild to moderate TBI. Intervention using an online programme (n=7) or task-oriented activities (n=15) was evaluated at three assessment intervals: on recruitment into the study (Assessment 1), on completion of inpatient hospital intervention (Assessment 2) and after four weeks of home programme intervention and fortnightly outpatient intervention (Assessment 3). Results: Results for both groups showed a statistically significant change for cognitive functional performance assessed on the Bay Area Functional Performance Evaluation (BaFPE) while the task-oriented cognitive training group also achieved a statistically significant change in bADL scores during the first inpatient assessment period. Only the online programme group had statistically significant improvement during the home programme in the third assessment period. Conclusion: Cognitive retraining using an online programme or task-oriented activities resulted in positive change in a therapist directed inpatient programme but a structured, graded, online programme was more effective in supporting significant improvement in cognitive functional performance when used with an outpatient home programme. Implications for practice Cognitive retraining using an online programme or task orientated activities have a positive outcome for cognitive functional performance in patients with mild or moderate TBI in a therapist directed inpatient intervention. A task orientated approach for cognitive retraining appears to have positive effect on bADL outcomes. Cognitive retraining using an online programme intervention should be considered as a home programme to improve cognitive functional performance in patients with mild or moderate TBI.

Psychological correlates of the good old days bias in mild traumatic brain injury

ABSTRACT Non-neurological factors such as the “expectation as etiology” or the “good old days” bias (EE/GOD bias) may partially explain persistent symptoms following mild traumatic brain injury (MTBI). What is less clear from existing research is the degree to which EE/GOD bias is related to other psychological correlates of persistent post-concussive symptoms (PPCS). We examined whether the EE/GOD bias was related to illness perception beliefs, intolerance of uncertainty, suggestibility, and domain identification. Participants with MTBI history and without (controls) reported frequency and severity of current PPCS; the MTBI group additionally reported premorbid PPCS. Participants also completed measures of psychological factors potentially associated with PPCS. Consistent with previous studies of the EE/GOD bias, the MTBI group endorsed less premorbid PPCS than current PPCS and when compared to the current symptom report of the control group. The MTBI group also endorsed more current PPCS than the control group. Higher EE/GOD bias was associated with several aspects of illness identity, including belief that symptoms would be more chronic, greater illness-related psychological distress, and greater cogniphobia. Higher EE/GOD bias was also related to higher intolerance of uncertainty and stronger personal identification with memory abilities. Regression showed that perceived symptom timeline, cogniphobia, and domain identification were unique predictors of EE/GOD bias. Findings confirm that the EE/GOD bias is seen in individuals with self-reported history of MTBI and corresponds to other psychological processes that potentially explain ongoing MTBI symptoms, providing greater insight into the potential mechanisms of PPCS. Future studies should examine the EE/GOD bias and associated psychological correlates in a clinical population and also assess for potential neuropsychological correlates. Findings suggest that psychological factors and premorbid symptom report should be considered in clinical assessment and also suggest potential mechanisms of treatment of individuals with acute MTBI or prolonged MTBI symptoms.

Self-reported dizziness, balance, and multisensory impairment following mild traumatic brain injury: an exploratory study

ABSTRACT Dizziness following mild traumatic brain injury (mTBI), or concussion, is common and can encompass multiple sensations reflecting diverse aetiologies. This exploratory study investigated the types of dizzy sensations experienced, their evolution, and relationship with other post-concussion symptoms. Thirty New Zealanders (24 female) aged 49 ± 16 years who experienced dizziness or imbalance following their injury completed the Dizziness Handicap Inventory, Visual Vertigo Analogue Scale, and the Hospital Anxiety and Depression Scale. Additional custom questionnaires probed subjective experiences of dizziness and balance, headaches, and difficulties with auditory processing and vision. Just over half the participants (56.7%) experienced a single mTBI. The median time interval since the injury was 16 months (IQR = 24 months). Participants usually reported multiple dizzy symptoms which developed within a week of the injury, although delays of up to six months were reported. Most participants (70%) felt their symptoms improved over time, while lack of improvement was associated with a history of multiple mTBI (P = 0.020). Moderate to strong correlations between questionnaire scores representing dizziness handicap, visual vertigo severity, and auditory processing difficulties (P < 0.001) suggest that dizziness and sensory impairment following mTBI are multi-modal and likely to benefit from holistic, multidisciplinary treatment.

Collaborative Care to Improve Quality of Life for Anxiety and Depression in Posttraumatic Epilepsy (CoCarePTE): Protocol for a Randomized Hybrid Effectiveness-Implementation Trial.

Anxiety and depression in people with epilepsy are common and associated with poor outcomes; yet, they often go untreated due to poor mental health specialist access. Collaborative care is an integrated care model with a strong evidence base in primary care and medical settings, but it has not been evaluated in neurology clinics. Evaluating implementation outcomes when translating evidence-based interventions to new clinical settings to inform future scaling and incorporation into real-world practice is important. The Collaborative Care for Posttraumatic Epilepsy (CoCarePTE) trial aims to evaluate the effectiveness (improvement in emotional quality of life) and implementation of a collaborative care intervention for people with anxiety or depressive symptoms and posttraumatic epilepsy. CoCarePTE is a 2-site, randomized, single-blind, hybrid type 1 effectiveness-implementation trial that will randomize 60 adults to receive either neurology-based collaborative care or usual care. Adults receiving neurological care at participating centers with anxiety or depressive symptoms and a history of at least mild traumatic brain injury before epilepsy onset will be enrolled. The collaborative care intervention is a 24-week stepped-care model with video or telephone calls every 2 weeks by a care manager for measurement-based anxiety and depression care, seizure care monitoring, and brief therapy intervention delivery. This is supplemented by antidepressant prescribing recommendations by psychiatrists for neurologists via case conferences and care manager-facilitated team communication. In step 2 of the intervention, individuals with <50% symptom reduction by 10 weeks will receive an added 8-session remote cognitive behavioral therapy program. The study is powered to detect a moderate improvement in emotional quality of life. As a hybrid type 1 trial, effectiveness is the primary focus, with the primary outcome being a change in emotional quality of life at 6 months in the intervention group compared to control. Secondary effectiveness outcomes are 6-month changes in depression, anxiety, and overall quality of life. Implementation outcomes, including fidelity, acceptability, feasibility, and appropriateness, are evaluated before implementation and at 3 months. The primary effectiveness analysis will compare changes in emotional quality of life scores from baseline to 6 months between the intervention and control arms using multiple linear regression modeling, adjusting for study site and using an intent-to-treat approach. Enrollment commenced in 2023, with modifications in the inclusion and exclusion made after the first 6 enrollees due to slow recruitment. Enrollment is expected to continue at least into early 2025. The CoCarePTE trial is novel in its use of a hybrid effectiveness-implementation design to evaluate an evidence-based mental health intervention in epilepsy, and by incorporating seizure care into a collaborative care model. If a significant improvement in emotional quality of life is found in the intervention group compared to usual care, this would support next step scaling or clinical implementation. ClinicalTrials.gov NCT05353452; https://www.clinicaltrials.gov/study/NCT05353452. DERR1-10.2196/59329.

Concussion leads to opposing sensorimotor effects of habituation deficit and fatigue in zebrafish larvae

Abstract Concussion, or mild traumatic brain injury, is caused by sudden mechanical forces impacting the brain either directly or through inertial loading. This can lead to physical, behavioural, and cognitive impairments 1. Despite concussion being a significant health issue, our understanding of the relationship between initial impact force and the subsequent neurological consequences is not well understood. Previously, we established a model of concussion in zebrafish larvae 2. Here we further investigate concussions of varying severities in zebrafish larvae using linear deceleration. Using an acoustic assay to monitor the larval sensorimotor behaviour 3, we found that different parameters of the resulting escape behaviour are modulated by the impact force of the preceding concussive insult. To investigate the relative contributions of habituation performance and fatigue on the escape response behaviour, we constructed a neurocomputational model. Our findings suggest that a concussive impact initially affects habituation performance at first and, as the impact force increases, fatigue is induced. Fatigue then alters the escape response behaviour in an opposing manner.

Optimal functioning after early mild traumatic brain injury: Evolution and predictors.

Early mild traumatic brain injury (mTBI or concussion sustained between 0 and 5 years old) can lead to post-concussive symptoms, behavioral changes, and cognitive difficulties. Although school-age children (6-17 years old) experience similar consequences, severe neuropsychological deficits are not common, and the majority have no persisting symptoms after one month. Thus, there may be value in focusing on what characterizes optimal functioning (or wellness) after mTBI, but this has not been explored in young children. This study documents the evolution and predictors of optimal functioning after early mTBI. Participants were 190 children aged 18 - 60 months with mTBI (n = 69), orthopedic injury (OI; n = 50), or typical development (TDC; n = 71). Optimal functioning was defined as: (1) no clinically significant behavioral problems; (2) no cognitive difficulties; (3) no persisting post-concussive symptoms; (4) average quality of life or better. Predictors related to sociodemographic, injury, child, and caregiver characteristics included number of acute symptoms, child sex, age, temperament, maternal education, parent-child attachment and interaction quality, and parenting stress. Fewer children with mTBI had optimal functioning over 6 and 18-months post-injury compared to those with OI and TDC. Higher parent-child interaction quality and lower child negative affectivity temperament independently predicted optimal functioning. Children who sustain early mTBI are less likely to exhibit optimal functioning thantheir peers in the long-term. Parent-child interaction quality could be a potential intervention target for promoting optimal function.

Comparative Study of Craniofacial Injuries in Skiing Versus Snowboarding: A NEISS Database Study

Introduction: Skiing and snowboarding are popular winter sports which are rising in popularity. There is a lack of detailed data in the literature regarding skiing and snowboarding head and neck injuries, especially the rate of concussions with helmet use. Methods: The authors queried the National Electronic Injury Surveillance System (NEISS) database to characterize patient demographics, injury types, subsite injured, and ED disposition associated with skiing and snowboarding-related head and neck injuries between 2009 and 2020 in the US. Results: An estimated 87,994 head and neck-related ski and snowboarding injuries were reported from 2011 to 2020 nationally. Ski-related and snowboard-related injuries comprised 51.9% and 48.1% of injuries, respectively. Ski-related injuries accounted for the majority of admissions (69.2%). Head injuries were the most common (68.3%), followed by injuries to the face (15.3%) and neck (12.2%). Concussions (57.7%) were the most common overall injury type and comprised 49.2% of admissions. Concussions were more common in snowboarding injuries (65.6% versus 50.3%, P&lt;0.001), whereas lacerations (11.1% versus 14.4%), contusion/abrasions (6.7% versus 11.1%), and fractures (2.9% versus 7.0%) were more common in ski-related injuries. Cases with negative helmet status were associated with a greater proportion of concussion injuries (79.8% versus 70.9%, P&lt;0.001). Conclusions: Patients presenting with skiing or snowboarding injuries require a thorough head and neck examination. A comprehensive history and physical should be performed with a focus on helmet use and evaluation for concussion, lacerations, and fractures. Helmet use is strongly recommended to prevent the risk of head injury. Level of Evidence: IV.

Differences in Brain Volume in Military Service Members and Veterans After Blast-Related Mild TBI: A LIMBIC-CENC Study.

Blast-related mild traumatic brain injuries (TBIs), the "signature injury" of post-9/11 conflicts, are associated with clinically relevant, long-term cognitive, psychological, and behavioral dysfunction and disability; however, the underlying neural mechanisms remain unclear. To investigate associations between a history of remote blast-related mild TBI and regional brain volume in a sample of US veterans and active duty service members. Prospective cohort study of US veterans and active duty service members from the Long-Term Impact of Military-Relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium (LIMBIC-CENC), which enrolled more than 1500 participants at 5 sites used in this analysis between 2014 and 2023. Participants were recruited from Veterans Affairs medical centers across the US; 774 veterans and active duty service members of the US military met eligibility criteria for this secondary analysis. Assessment dates were from January 6, 2015, to March 31, 2023; processing and analysis dates were from August 1, 2023, to January 15, 2024. All participants had combat exposure, and 82% had 1 or more lifetime mild TBIs with variable injury mechanisms. Regional brain volume was calculated using tensor-based morphometry on 3-dimensional, T1-weighted magnetic resonance imaging scans; history of TBI, including history of blast-related mild TBI, was assessed by structured clinical interview. Cognitive performance and psychiatric symptoms were assessed with a battery of validated instruments. We hypothesized that regional volume would be smaller in the blast-related mild TBI group and that this would be associated with cognitive performance. A total of 774 veterans (670 [87%] male; mean [SD] age, 40.1 [9.8] years; 260 [34%] with blast-related TBI) were included in the sample. Individuals with a history of blast-related mild TBI had smaller brain volumes than individuals without a history of blast-related mild TBI (which includes uninjured individuals and those with non-blast-related mild TBI) in several clusters, with the largest centered bilaterally in the superior corona radiata and subcortical gray and white matter (cluster peak Cohen d range, -0.23 to -0.38; mean [SD] Cohen d, 0.28 [0.03]). Additionally, causal mediation analysis revealed that these volume differences significantly mediated the association between blast-related mild TBI and performance on measures of working memory and processing speed. In this cohort study of 774 veterans and active duty service members, robust volume differences associated with blast-related TBI were identified. Furthermore, these volume differences significantly mediated the association between blast-related mild TBI and cognitive function, indicating that this pattern of brain differences may have implications for daily functioning.

Hypotension and Adverse Outcomes in Moderate to Severe Traumatic Brain Injury: A Systematic Review and Meta-Analysis.

Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Hypotension in patients with TBI is associated with poorer outcomes. A comprehensive review examining adverse outcomes of hypotension in patients with TBI is needed. To investigate the mortality and incidence of hypotension in patients with TBI. A search of studies published before April 2024 was conducted using MEDLINE, MEDLINE In Process, ePubs, Embase, Classic+Embase, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews for primary research articles in English, including randomized control trials, quasirandomized studies, prospective cohorts, retrospective studies, longitudinal studies, and cross-sectional surveys. Inclusion criteria were patients aged at least 10 years with moderate to severe TBI with hypotension. The exclusion criteria were mild TBI (due to the differences in management principles from moderate to severe TBI). Data were screened using Covidence software with multiple reviewers. This meta-analysis conforms to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guidelines for assessing data quality and validity. Primary outcomes (unadjusted and adjusted odds ratios [ORs]) were calculated using a random-effect model with 95% CIs. Incidence of hypotension was derived using logit transformation. Main outcomes were association of hypotension with death and/or vegetative state within 6 months and incidence of hypotension. Vegetative state was not reported due to lack of data from included studies. Hypothesis testing occurred before data collection. The search strategy identified 17 676 unique articles. The final review included 51 studies (384 329 patients). Pooled analysis of found a significant increase in mortality in patients with hypotension and moderate to severe TBI (crude OR, 3.82; 95% CI, 3.04-4.81; P < .001; I2 = 96.98%; adjusted OR, 2.22; 95% CI, 1.96-2.51; P < .001; I2 = 92.21%). The overall hypotension incidence was 18% (95% CI, 12%-26%) (P < .001; I2 = 99.84%). This meta-analysis of nearly 400 000 patients with TBI found a significant association of greater than 2-fold odds of mortality in patients with hypotension and TBI. This comprehensive analysis can guide future management recommendations, specifically with respect to blood pressure threshold management to reduce deaths when treating patients with TBI.

Evaluation of Visual Disturbances After Mild Traumatic Brain Injury-A One-Year Follow-up Study.

To examine the persistence of visual symptoms in mild traumatic brain injury (MTBI) during the first months after injury. It is important to recognize visual disturbances because they can delay return to normal activities, while they might be simultaneously treated by visual therapy. Here we describe the results from a 1-year follow-up study of visual disturbances after MTBI. The study group comprised 26 patients from the Brain Injury Clinic of the Helsinki University Hospital. Inclusion criterion was a high score (≥21p) on the Convergence Insufficiency Symptom Survey (CISS) at an appointment with a neurologist within 6months after injury. The patients underwent baseline vision evaluation at 4months on average and follow-up at 14months after injury. The evaluation included tests for visual acuity, near point of convergence, convergence facility, near point of accommodation, accommodative facility, motility, heterophoria, binocular vision, dynamic visual acuity, and fusional vergence width at near and far distances. Further assessments included the Rivermead Post Concussion Questionnaire for posttraumatic symptoms, a visual analog scale for visual fatigue, and the Developmental Eye Movement Test for saccadic eye movements. Both CISS and Rivermead Post Concussion Questionnaire scores improved significantly from baseline to follow-up. The overall level of visual fatigue according to visual analog scale score was lower at follow-up, but the increase in visual fatigue (comparing fatigue before and after assessment session) was significant both at baseline and follow-up. In visual function assessments, spontaneous recovery from baseline to follow-up could be seen in vergence facility and pursuit eye movement but not in near point of convergence, near fusion, distance fusion, heterophoria, and dynamic visual acuity. The results point out the importance of evaluation of visual disturbances after MTBI. Early detection of these disturbances may provide an opportunity to provide visual therapy.

Validating the Brain Injury Guidelines in a Pediatric Population with Mild Traumatic Brain Injury and Intracranial Injury at a Level I Trauma Center.

Children with mild traumatic brain injury (mTBI) and intracranial injury (ICI) often receive unnecessary imaging and hospital admission, leading to avoidable burdens on patients and health systems. While most of these patients do not develop critical neurological injuries, identifying those at risk would allow for a more optimal determination of the appropriate level of initial emergency care. The Brain Injury Guidelines (BIG) were developed as a triage tool to identify adult patients with mTBI and ICI who can benefit from repeat imaging, hospital admission, or neurosurgical consultation. Here, we sought to validate BIG in children at a Level I trauma center and determine if the BIG algorithm can accurately identify which patients with mTBI/ICI have critical neurosurgical injuries. We hypothesize that the BIG can identify critical neurological injuries more accurately than the Glasgow Coma Scale (GCS) alone and that more severe injury according to BIG is associated with worse patient outcome. We retrospectively reviewed TBI admissions at a single center (2017-2023) using an institutional registry. Patients included (0-17 years) had an initial head computerized tomography scan with ICI and a GCS of 14-15. Patients were retrospectively classified into the BIG categories (BIG 1, 2, or 3). Medical records were reviewed to identify clinically important TBI (ciTBI): death, neurological deterioration, neurosurgical intervention, intubation >24 h, or hospital admission >48 h due to TBI. Repeat imaging studies obtained were evaluated for progression of injury. The incidence of clinically important TBI (ciTBI) and imaging progression were recorded and compared across BIG categories. Outcomes were evaluated using the Glasgow Outcome Score Extended (GOS-E) 6 months after injury. Univariable and chi-square tests were used to analyze comparisons. Overall, 804 subjects were included in the analysis of which 551 (68.5%) were transfers. Overall, 175 (21.8%) patients had a BIG 1, 402 (50.0%) a BIG 2, and 227 (28.2%) a BIG 3 injury. CiTBI occurred among 64 (8.0%) patients overall, and in 1 (0.6%), 4 (1.0%), and 59 (26.0%) of the BIG 1, 2, and 3 injuries (p < 0.0001). Progression on repeat imaging associated with neurological decline, neurosurgical intervention or resulting in additional evaluation was noted in 0 (0%), 2 (0.5%), and 41 (18.0%) of the BIG 1, 2, and 3 injuries (p < 0.001). Amongst 471 patients (58.6%) with available 6-month patient outcomes, 98% had a GOS-E ≥5 and no outcome difference between BIG categories was observed. Risk stratification of mild TBI using BIG allowed for reasonable identification of children who subsequently develop ciTBI, suggesting that BIG classification can aid in triage and management of patients who might benefit from neurosurgical consultation, repeat imaging, and potentially transfer to a dedicated trauma center. More severe injury according to BIG was not associated with a worse patient outcome.

Systematic vitamin K antagonist reversal with prothrombin complex concentrate in patients with mild traumatic brain injury: randomized controlled trial.

Traumatic brain injury (TBI) in patients on vitamin K antagonists (VKAs) is linked to a high rate of intracranial hemorrhage (ICH). Rapid reversal can reduce ICH progression and mortality, but its effectiveness depends on the time between bleeding onset and coagulation normalization. The PREVACT study aimed to assess the efficacy and safety of prompt systematic reversal of anticoagulation in patients presenting to emergency departments (EDs) for recent mild-TBI while receiving a VKA. A randomized, open-label, blinded-endpoint clinical trial was conducted in 21 French EDs. Patients receiving a VKA, having experienced a TBI within the last 6 h, and presenting a Glasgow Coma Score ≥13 were included. Patients were randomized to systematic immediate VKA reversal with 25 IU/kg of four-factor prothrombin complex concentrate (4f-PCC) before any investigation (intervention group) or standard-of-care signifying reversal only if the initial cranial computed tomography (CT) scan indicated ICH (control group). The primary outcome was the rate of ICH detected on a cranial CT scan 24 h post-inclusion. The study was prematurely stopped for logistic reasons after the randomization of 202 patients (101 and 101 in the intervention and control groups, respectively, mean age 90; 51.8% female). On the 24-h cranial CT scan, 6 of 98 patients (6.1%) in the intervention group manifested ICH vs. 12 of 99 patients (12.1%) in the control group [odds ratio: 0.47 (95% confidence interval: 0.14-1.44); P = 0.215]. In patients with recent mild-TBI receiving a VKA, systematic prompt reversal with 4f-PCC did not statistically significantly reduce ICH rate at 24 h. However, the study was prematurely stopped and does not exclude a clinically relevant benefit of the strategy tested. Clinicaltrials.gov (NCT01961804).

Anatomic Interpretability in Neuroimage Deep Learning: Saliency Approaches for Typical Aging and Traumatic Brain Injury.

The black box nature of deep neural networks (DNNs) makes researchers and clinicians hesitant to rely on their findings. Saliency maps can enhance DNN explainability by suggesting the anatomic localization of relevant brain features. This study compares seven popular attribution-based saliency approaches to assign neuroanatomic interpretability to DNNs that estimate biological brain age (BA) from magnetic resonance imaging (MRI). Cognitively normal (CN) adults (N = 13,394, 5,900 males; mean age: 65.82 ± 8.89years) are included for DNN training, testing, validation, and saliency map generation to estimate BA. To study saliency robustness to the presence of anatomic deviations from normality, saliency maps are also generated for adults with mild traumatic brain injury (mTBI, = 214, 135 males; mean age: 55.3 ± 9.9years). We assess saliency methods' capacities to capture known anatomic features of brain aging and compare them to a surrogate ground truth whose anatomic saliency is known a priori. Anatomic aging features are identified most reliably by the integrated gradients method, which outperforms all others through its ability to localize relevant anatomic features. Gradient Shapley additive explanations, input × gradient, and masked gradient perform less consistently but still highlight ubiquitous neuroanatomic features of aging (ventricle dilation, hippocampal atrophy, sulcal widening). Saliency methods involving gradient saliency, guided backpropagation, and guided gradient-weight class attribution mapping localize saliency outside the brain, which is undesirable. Our research suggests the relative tradeoffs of saliency methods to interpret DNN findings during BA estimation in typical aging and after mTBI.

The vague language use scale: Clinical utility and psychometrics from adults with traumatic brain injury.

Pragmatic communication difficulties encompass many distinct behaviours, including the use of vague and/or insufficient language, a common characteristic following traumatic brain injury (TBI) that negatively impacts psychosocial outcomes. Existing assessments evaluate pragmatic communication broadly, often with only one or two items capturing each behaviour, thus limiting sensitivity and precision to variations within each behaviour. Given that greater nuance is needed to detect subtle pragmatic communication differences and investigate underlying cognitive mechanisms, a more refined measure is critical to improve psychosocial outcomes. The Vague scale was developed to address those needs. To provide preliminary evidence supporting the novel Vague language use (Vague) scale's reliability, validity and clinical utility. The Vague scale rates each discourse sample utterance for vague language use on a 3-point scale; the measure's Vague score represents the mean of utterance-level ratings. Using the Vague scale, two raters naïve to diagnosis evaluated Cinderella narratives of 46 adults with severe TBI and 46 controls with no brain injury, providing reliability, construct validity and classification accuracy evidence. Vague scores were also compared to other clinical measures to gather criterion-related validity evidence. Interrater agreement across all transcripts was moderate. Construct validity was supported by expected group differences and criterion validation, including significant relationships with increased violations of Grice's maxim of quantity and measures of lexical variation; significant relationships with psychosocial outcomes, supporting clinical utility; and nonsignificant relationships with measures of syntax and overall pragmatic communication. Classification accuracy expectedly did not support using Vague scores in isolation for diagnosis, due to unacceptable sensitivity (0.696). Evidence supported the Vague scores' psychometric properties. Thus, the Vague scale shows promise as a measure of one distinct pragmatic communication behaviour: vague language use. Future research should apply the Vague scale to determine its sensitivity in individuals with subtle social communication challenges (e.g., mild TBI), explore its utility with more naturalistic discourse samples as part of a pragmatic communication battery, longitudinally examine changes in Vague scores, and investigate cognitive mechanisms underlying this specific pragmatic communication behaviour. What is already known on this subject Use of vague language is common following traumatic brain injury (TBI) and may contribute to negative psychosocial outcomes related to employment and relationships. However, existing measures of vague language lack sensitivity and precision, limiting their utility for identifying subtle performance variations or determining the cognitive mechanisms underlying this specific pragmatic communication behaviour. What this study adds to existing knowledge The current study gathered promising reliability, validity and clinical utility evidence to support using the novel Vague language use (Vague) scale, which was developed to address these limitations. Based on complex (Cinderella) stories of adults with and without TBI, Vague scores demonstrated moderate interrater agreement and promising construct validity based on expected group differences and criterion validation, including moderate associations with related constructs and weak associations with unrelated constructs. Because pragmatic communication profiles post-TBI can vary, classification accuracy expectedly indicated that Vague scores should not be used alone to identify communication differences post-TBI. What are the clinical implications of this work? Vague scores show promise for documenting clients' use of vague language and planning intervention to address associated discourse-level challenges. Future research should investigate applying the Vague scale to naturalistic discourse samples (1) as part of a battery that sensitively and precisely identifies pragmatic communication differences and (2) as a tool for investigating cognitive mechanisms underlying vague language use, with the goal of improving interventions that support pragmatic communication and enhance psychosocial outcomes.

Peri-injury symptomatology as predictors of brain computed tomography (CT) scan abnormalities in mild traumatic brain injury (mTBI)

ObjectiveThis study aimed to identify predictors of brain CT abnormalities in patients who sustained a mild traumatic brain injury (mTBI).MethodsRetrospective observational cohort of adult patients with mTBI (Glasgow Coma Score 13–15) that occurred within the preceding 24 h.Results2548 (91%) of the cohort had a brain CT and 698 (27%) demonstrated abnormal findings. The most frequently observed CT abnormalities were bleeding (638, 25%) and fractures (190, 7.4%). Multivariate logistic regression analysis revealed several significant predictors associated with the presence of brain CT abnormalities including older age [P < 0.0001], male sex [P < 0.0001], loss of consciousness [P = 0.0041], associated vomiting [P = 0.0011], alteration of consciousness (AOC) [P = 0102], and GCS score [P < 0.0001]. This was a robust model with an R² of 14.2%.ConclusionIn this retrospective analysis, older age, male sex, the presence of loss of consciousness or alteration in consciousness, lower GCS score, and associated vomiting were found to be significant predictors of having an abnormal brain CT. These findings highlight the importance of considering these factors when determining the necessity of brain CT scans in patients with mTBI and suggest that existing clinical decision rules may be limited. These findings may also help to inform clinical decision rules. Early identification of individuals at a higher risk of CT abnormalities may assist in appropriate management and allocation of healthcare resources.

Utilisation of New Zealand Rugby's concussion management pathway: A mixed methods investigation.

Concerns around concussion highlight the need for strategies to improve the implementation and translation of concussion guidelines in community sports. This study assessed players' utilisation and compliance with New Zealand Rugby's Concussion Management Pathway (CMP). This pragmatic, mixed methods study comprised of concussion injury surveillance and mapping of players' healthcare touchpoints through the CMP. Semi-structured interviews were conducted to understand stakeholders' experiences. Over the season, 27 different healthcare pathways were identified with 28% of players progressing through all phases of the CMP (ideal pathway). Of the 206 suspected concussions reported over the season, 70% were logged in the CMP phone App, and 89% of these had an associated valid baseline concussion assessment. Prior to returning to contact training, 64% of players obtained a medical clearance. One theme, 'belief in the value of pathway' was identified as a facilitator across all CMP components. Themes such as 'concussion knowledge and the nature of concussion'; 'communication between stakeholders and sufficient information on the process'; and 'strong relationships and clarity around responsibilities' were identified as facilitators across several pathway components. Other facilitators included 'ease and timing of general practitioner access'; 'the phone App as facilitator to logging'; and 'spotting for concussion as a team'. Additionally, the findings signify baseline testing as a potential pre-cursor to overall CMP compliance. Strategies that support the facilitators identified in this study may further enhance compliance.

Comparison of three different ice hockey helmets using an ice hockey specific test protocol

Although there are currently no standard tests measuring rotational head motion for ice hockey, researchers have proposed test methods which induce rotational head motion from an impact and may reflect more closely how concussions occur in the sport. Recently, Meehan et al. developed a test method for ice hockey helmets to represent concussive injuries associated with ice hockey. While that provided a method that used impact parameters closer to what may be experienced, the research did not evaluate if different helmets would produce differing results under those loading conditions. The purpose of this study is to use the methods developed by Meehan et al. to evaluate the protective capacity of three different ice hockey helmet designs. This research used monorail drop rig and pneumatic ram systems to follow the protocol of Meehan with a bare headform condition and three different helmet designs, allowing for differences in linear and rotational acceleration, rotational velocity, and maximum principal strain to be determined. The results of this research found that the test method developed by Meehan et al. does result in significant differences between different helmets and helmet designs under identical impact conditions. However, these differences were limited which may be a reflection of the test method as well as commonality in terms of how ice hockey helmets are designed; the different models may not be sufficiently different enough to provide different results under these loading conditions.

Mechanisms of Injury for Traumatic Brain Injury Among U.S. Military Service Members Before and During the COVID-19 Pandemic.

To understand the mechanisms of injury and demographic risk factors associated with traumatic brain injury (TBI) patients among active and reserve service members in the U.S. Military before and during the COVID-10 pandemic. Active and reserve service members diagnosed with an incident TBI from January 2019 through September 2021 were selected. Traumatic brain injury patients diagnosed before March 1, 2020 were categorized as pre-COVID (PC), and patients diagnosed on or after March 1, 2020 were categorized as the intra-COVID (IC) group, aligning closely with the date when the World Health Organization officially proclaimed the pandemic. We determined the frequency of causes of injuries associated with TBI separate by sex, age, occupation, and TBI severity. In addition, we conducted multivariate logistic regression analyses to assess the demographic risk factors associated with TBI severity during the PC and IC eras. Our cohort included 48,562 TBI patients: 22,819 (47.0%) diagnosed during the PC era and 25,743 (53.0%) diagnosed during the IC era. The major mechanisms of injury within our TBI cohort were being struck by/against objects, falls/slips/trips, and motor vehicle traffic accidents before and during the pandemic. The most common causes of TBI were not impacted by COVID, but motor vehicle accidents did increase during the IC era. The mechanisms of injury associated with TBI differed by TBI severity: being struck by or against an object caused more mild and moderate TBI; motor vehicle accidents caused more severe TBI; and firearms was a major cause of penetrating TBI. In addition, the percentage of severe TBI because of firearms rose sharply during the IC era. Further, women were more likely to be diagnosed with mild TBI compared to men. Military leaders should consider how different causes of injury are associated with differing TBI severities and how certain demographic groups were vulnerable to specific TBI severities when developing injury prevention programs.

Science of Mild Traumatic Brain Injury

Mild traumatic brain injury (TBI) is commonly encountered in daily medical practice. Approximately half of all patients with mild TBI develop postconcussional syndrome, and post-traumatic higher brain dysfunction is a cause of many social problems. This article defines and explains the diagnosis, pathology, symptoms, and sequelae of mild TBI from a scientific perspective, and "mild blast-induced TBI," which has recently become a major problem in military medicine, is also introduced.

Transcriptional signatures of gray matter volume changes in mild traumatic brain injury

BackgroundNeuroimaging studies have shown that patients with mild traumatic brain injury (mTBI) often exhibit changes in gray matter volume (GMV) in the brain. However, the results regarding these changes are inconsistent, and the underlying molecular mechanisms remain unclear. This study aimed to investigate GMV changes in mTBI patients and uncover the molecular mechanisms driving these alterations. MethodsWe conducted a neuroimaging meta-analysis on nine studies, involving 396 mTBI patients and 338 healthy controls, to identify consistent patterns of GMV changes. Additionally, we utilized the Allen Human Brain Atlas database to explore transcriptome-neuroimaging spatial correlations, identifying genes whose expression profiles are linked to GMV changes in mTBI patients. Enrichment analyses were also performed to determine the biological significance of the altered GMV-related genes. ResultsWe observed consistent GMV increases in the bilateral middle cingulate/paracingulate gyri, right striatum, and right dorsolateral superior frontal gyrus, along with GMV decreases in the right insula and left lingual gyrus. Moreover, we found spatial associations between mTBI-related GMV changes and the expression of 977 genes, which were primarily enriched in specific biological processes, body tissues, and developmental time windows of the cerebral cortex. ConclusionOur findings improve the understanding of GMV abnormalities in mTBI patients and provide insights into the molecular mechanisms underlying these changes.