Severity Of Post-concussion Symptoms Research Articles

Brain structural and functional abnormalities associated with acute post-traumatic headache: iron deposition and functional connectivity

BackgroundThe purpose of this study was to interrogate brain iron accumulation in participants with acute post-traumatic headache (PTH) due to mild traumatic brain injury (mTBI), and to determine if functional connectivity is affected in areas with iron accumulation. We aimed to examine the correlations between iron accumulation and headache frequency, post-concussion symptom severity, number of mTBIs, and time since most recent TBI.MethodsSixty participants with acute PTH and 60 age-matched healthy controls (HC) underwent 3T magnetic resonance imaging including quantitative T2* maps and resting-state functional connectivity imaging. Between group T2* differences were determined using T-tests (p < 0.005, cluster size threshold of 90 voxels). For regions with T2* differences, two analyses were conducted. First, the correlations with clinical variables including headache frequency, number of lifetime mTBIs, time since most recent mTBI, and Sport Concussion Assessment Tool (SCAT) symptom severity scale scores were investigated using linear regression. Second, the functional connectivity of these regions with the rest of the brain was examined (significance of p < 0.05 with family wise error correction for multiple comparisons).ResultsThe acute PTH group consisted of 60 participants (22 male, 38 female) with average age of 42 ± 14 years. The HC group consisted of 60 age-matched controls (17 male, 43 female, average age of 42 ± 13). PTH participants had lower T2* values compared to HC in the left posterior cingulate and the bilateral cuneus. Stronger functional connectivity was observed between bilateral cuneus and right cerebellar areas in PTH compared to HC. Within the PTH group, linear regression showed negative associations of T2* in the left posterior cingulate with SCAT symptom severity score (p = 0.05) and T2* in the left cuneus with headache frequency (p = 0.04).ConclusionsIron accumulation in posterior cingulate and cuneus was observed in those with acute PTH relative to HC; stronger functional connectivity was detected between the bilateral cuneus and the right cerebellum. The correlations of decreased T2* (suggesting higher iron content) with headache frequency and post mTBI symptom severity suggest that the iron accumulation that results from mTBI might reflect the severity of underlying mTBI pathophysiology and associate with post-mTBI symptom severity including PTH.

176 Repetitive Traumatic Brain Injuries Are Associated With Poorer Outcomes at 1-Year and 3-7 Years After Index Injury

INTRODUCTION: Traumatic brain injury (TBI) patients are at risk for subsequent TBIs. Research on the longitudinal impact of repetitive TBI is limited. METHODS: The 18-center TRACK-TBI study enrolled subjects who presented to hospital and received head computed tomography (CT) within 24-hours of TBI between 2014-2018. Subjects were interviewed regarding post-index TBI during follow-up. Data from subjects aged = 17-years with 1-year or 3-7-year outcomes were extracted. Outcome measures included functional (GOSE:Glasgow Outcome Scale-Extended), post-concussive symptoms (PCS) (RPQ:Rivermead Post-Concussion Symptoms Questionnaire), psychological distress (BSI-18:Brief Symptom Inventory-18), depression (PHQ-9:Patient Health Questionnaire-9), post-traumatic stress disorder (PCL-5:PTSD-Checklist for DSM-5), and quality of life (QOL) (QOLIBRI-OS:Quality of Life After Brain Injury-Overall Scale). Multivariable regressions were adjusted for demographic, socioeconomic, and injury severity factors, and for multiple comparisons. Mean-differences (B), relative risks (RR), and 95% confidence intervals [CI] were reported. RESULTS: In 1,572 subjects, 3.2% and 12.2% sustained post-index TBI at 1-year and 3-7-years, respectively; 2.4% sustained multiple post-index TBIs at 3-7-years. Risk factors included psychiatric history, prior TBI, and extracranial injury severity. At 1-year, post-index TBI was independently associated with incomplete recovery (GOSE&lt;8; RR = 1.75 [1.04-2.94]), decreased QOL (QOLIBRI-OS: B = -15.9 [-22.6, -9.1]), and increased severity of PCS, psychological distress, PTSD, and depression (RPQ: B = 8.1 [4.2-11.9], BSI-18: B = 5.3 [2.1-8.6]; PCL-5: B = 7.8 [3.2-12.4]; PHQ-9: B = 3.0 [1.5-4.4]); effects were conserved at reduced magnitudes at 3-7-years. Multiple (=2 vs. 1) post-index TBIs were associated with greater symptom severities across all outcome measures. CONCLUSIONS: Post-index TBI is associated with incomplete functional recovery, increased PCS, psychological distress, PTSD, and depressive symptom severities, and decreased QOL at 1- and 3-7-years post-injury. Sustaining multiple post-index TBIs further increases symptom severity across all outcome domains. Institutional processes and resources for TBI prevention, education, counseling, and follow-up are greatly needed.

Cognitive Behavioral Therapy for Insomnia Improves Sleep Outcomes in Individuals With Concussion: A Preliminary Randomized Wait-List Control Study.

Cognitive behavioral therapy for insomnia (CBT-I) is the gold standard treatment for insomnia, but there is limited evidence on the treatment effect of CBT-I in individuals after a concussion. Therefore, the main purpose of this study was to evaluate the treatment effect of CBT-I on sleep outcomes and postconcussion symptoms. This study was conducted at an academic institution. The CBT-I sessions were conducted using a teleconferencing system (Zoom). Participants were eligible to participate if they were at least 4 weeks post- concussion, aged 18 to 64 years, and scored 10 or more on the Insomnia Severity Index. A total of 40 people were enrolled; 32 participants were included in analyses. This was a randomized controlled wait-list study. Participants were randomized into starting the CBT-I intervention immediately after the baseline assessment or into the wait-list group for 6 weeks before starting CBT-I. Assessments were performed at baseline, 6, 12, and 18 weeks. The primary outcome was the Insomnia Severity Index. Secondary measures included the Pittsburg Sleep Quality Index, Post-Concussion Symptom Scale, and Beck Depression and Anxiety Inventories. Statistical analyses included a repeated-measures analysis of variance, t tests, and mixed linear regression modeling. There was a group-by-time interaction for the sleep outcomes but not for the concussion or mood outcomes. Differences were seen between groups on sleep outcomes, symptom severity, and depression. The treatment effect was maintained following CBT-I for all outcomes. Improvement in sleep outcomes was predictive of improvement in postconcussion symptom severity and number of symptoms. CBT-I reduces insomnia in individuals with concussions, and improved sleep was associated with lower postconcussion and mood symptoms. These effects were maintained 6 to 12 weeks following the intervention.

Telomere Length Associates With Symptom Severity After Mild Traumatic Brain Injury in Older Adults.

The objectives were to compare differences in telomere length (TL) among younger (21-54 years) and older adults (≥55) with mild traumatic brain injury (mTBI) to non-injured controls and to examine the association between TL and the severity of post-concussive symptoms over time. We performed a quantitative polymerase chain reaction to determine the TL (Kb/genome) of peripheral blood mononuclear cell samples (day 0, 3 months, and 6 months) from 31 subjects. The Rivermead Post-Concussion Symptoms Questionnaire was used to assess symptoms. Group-by-time comparisons of TL and symptom severity were evaluated with repeated-measures analysis of variance. Multiple linear regression examined the relationship between TL, group (mTBI and non-injured controls), and symptom severity total and subscale scores. Significant aging-related differences in TL were found within mTBI groups by time (day 0, 3 months, and 6 months; p = 0.025). Older adults with mTBI experienced significant worsening of changes in total symptom severity scores over time (day 0, 3 months, and 6 months; p = 0.016). Shorter TLs were associated with higher total symptom burden among each of the four groups at day 0 (baseline; p = 0.035) and 3 months (p = 0.038). Shorter TL was also associated with higher cognitive symptom burden among the four groups at day 0 (p = 0.008) and 3 months (p = 0.008). Shorter TL was associated with higher post-injury symptom burden to 3 months in both older and younger persons with mTBI. Large-scale, longitudinal studies of factors associated with TL may be useful to delineate the mechanistic underpinnings of higher symptom burden in adults with mTBI.

Selective head cooling in the acute phase of concussive injury: a neuroimaging study

IntroductionNeurovascular decoupling is a common consequence after brain injuries like sports-related concussion. Failure to appropriately match cerebral blood flow (CBF) with increases in metabolic demands of the brain can lead to alterations in neurological function and symptom presentation. Therapeutic hypothermia has been used in medicine for neuroprotection and has been shown to improve outcome. This study aimed to examine the real time effect of selective head cooling on healthy controls and concussed athletes via magnetic resonance spectroscopy (MRS) and arterial spin labeling (ASL) measures.Methods24 participants (12 controls; 12 concussed) underwent study procedures including the Post-Concussion Symptom Severity (PCSS) Rating Form and an MRI cooling protocol (pre-cooling (T1 MPRAGE, ASL, single volume spectroscopy (SVS)); during cooling (ASL, SVS)).ResultsResults showed general decreases in brain temperature as a function of time for both groups. Repeated measures ANOVA showed a significant main effect of time (F = 7.94, p &amp;lt; 0.001) and group (F = 22.21, p &amp;lt; 0.001) on temperature, but no significant interaction of group and time (F = 1.36, p = 0.237). CBF assessed via ASL was non-significantly lower in concussed individuals at pre-cooling and generalized linear mixed model analyses demonstrated a significant main effect of time for the occipital left ROI (F = 11.29, p = 0.002) and occipital right ROI (F = 13.39, p = 0.001). There was no relationship between any MRI metric and PCSS symptom burden.DiscussionThese findings suggest the feasibility of MRS thermometry to monitor alterations of brain temperature in concussed athletes and that metabolic responses in response to cooling after concussion may differ from controls.

Dizziness Directly Influences Postconcussion Symptoms and Is Predictive of Poorer Mental Health in UK Military Personnel: A Retrospective Analysis.

To investigate the contribution of dizziness to postconcussion symptoms, depression, and anxiety symptoms. Mild traumatic brain injury (mTBI) service, Defence Medical Rehabilitation Centre, Stanford Hall. Two hundred eighty-three UK military personnel from the Royal Navy, Royal Airforce, Royal Marines, and British Army. A retrospective analysis of data from the Ministry of Defence medical records database. Sixteen-item Rivermead Post Concussion Symptoms Questionnaire, Generalized Anxiety Disorder 7-item scale, Patient Health Questionnaire-9, The Dizziness Handicap Inventory. Injuries from sports or falls were the most common mechanism of mTBI, accounting for 23%, respectively. Chi-square analysis indicated that individuals with dizziness and postconcussion symptoms (PCS) had greater severity of PCS, depression, and anxiety than those with PCS alone. Mediation analysis showed dizziness directly and independently influenced the severity of PCS, despite the indirect effects of mediating depression and anxiety symptoms. Comorbid dizziness and PCS were predictive of poorer mental health compared with PCS alone. In addition, dizziness directly influenced the severity of PCS irrespective of the indirect effects of mental health symptoms. These observations suggest that treating dizziness with vestibular rehabilitation may improve PCS and mental health.

Altered Oculomotor and Vestibulo-ocular Function in Children and Adolescents Postconcussion.

To document (1) oculomotor (OM) and vestibulo-ocular (VO) function in children with concussion who were symptomatic at the time of assessment and to compare it with that in children with concussion who were clinically recovered (asymptomatic) and in children with no concussive injury, and (2) the extent to which OM and VO function relates to postconcussion symptom severity in injured children. Participants were recruited from a concussion clinic or the community. A total of 108 youth with concussion (72 symptomatic; 36 recovered) and 79 healthy youth (aged 9-18 years). Youth with concussion were included if aged 9 to 18 years, had no previous concussion within the last 12 months, less than 90 days since injury, and no known existing visual disorders or learning disabilities. A prospective cross-sectional study. All participants were tested for OM and VO function with a commercial virtual reality (VR) eye-tracking system (Neuroflex®, Montreal,Québec, Canada). Participants in the concussion group who completed the postconcussion symptoms were scored with the Post-Concussion Symptom Inventory. There was a significant group effect for vergence during smooth pursuit (F2,176 = 10.90; P < .05), mean latency during saccades (F2,171 = 5.99; P = .003), and mean response delay during antisaccades (F2,177 = 9.07; P < .05), where children with symptomatic concussion showed poorer performance than clinically recovered and healthy children. Similar results were found in VO for average vestibular ocular reflex gain in the horizontal leftward (F2,168 = 7; P = .001) and rightward directions (F2,163 = 13.08; P < .05) and vertical upward (F2,147 = 7.60; P = .001) and downward directions (F2,144 = 13.70; P < .05). Mean saccade error was positively correlated to total Post-Concussion Symptom Inventory scores in younger clinically recovered children. VR eye tracking may be an effective tool for identifying OM and VO deficits in the subacute phase (<90 days) postconcussion.

Post-Concussion Symptoms in Women With Head Injury Due to Intimate Partner Violence.

Limited research has examined the symptom sequelae of head injuries in women survivors of intimate partner violence (IPV), despite this community being at increased risk for neurotrauma due to partner abuse. The current study compared post-concussion symptom severity between women with and without IPV-related head injuries. Women were recruited from court jurisdictions in Kentucky, USA, after receiving a protective order for partner abuse. The sample included 268 women with no prior head injuries (age: M[standard deviation (SD)] = 31.8[9.8], 77.2% White) and 251 women with lifetime IPV-related head injuries (age: M[SD] = 31.8[9.8], 88.0% White). Women with IPV-related head injuries were slightly older (t = 2.46, p = 0.014) with lower education (χ2 = 5.81, p = 0.016), were more frequently unemployed (χ2 = 9.23, p = 0.002), and had a higher likelihood of residing in a rural setting (χ2 = 30.16, p < 0.001). Women with IPV-related head injuries were also more often White (χ2 = 10.47, p = 0.001), but this group difference was almost entirely related to rural versus urban residence. Women with IPV-related head injuries reported a higher severity of lifetime physical IPV (t = 7.27, p < 0.001, d = 0.64, 95% confidence interval [CI]: [.46, .82]) and sexual IPV (t = 4.65, p < 0.001, d = 0.41 [0.24, 0.59]). A three-factor model of post-concussion symptoms, inclusive of cognitive, physical, and emotional symptoms, fit well (χ2 = 368.99, p < 0.0001, comparative fit index [CFI] = 0.974, Tucker-Lewis index [TLI] = 0.968, root mean square error of approximation [RMSEA] = 0.079 [0.071, 0.087]), and showed evidence for strong measurement invariance across women with and without IPV-related head injuries. The subscale and total scores each had acceptable reliability: cognitive (ω = 0.88 [0.86, 0.90]), physical (ω = 0.74 [0.70, 0.77]), and emotional (ω = 0.88 [0.86, 0.89]), and total score (ω = 0.93 [0.92, 0.95]). Women with IPV-related head injuries reported all individual post-concussion symptoms at a significantly higher frequency, with medium group differences in cognitive (t = 7.57, p < 0.001, d = 0.67 [0.50, 0.85]) and physical symptoms (t = 7.73, p < 0.001, d = 0.68 [0.51, 0.86]) and large group differences in emotional (t = 8.51, p < 0.001, d = 0.75 [0.57, 0.93]) and total symptoms (t = 9.07, p < 0.001, d = 0.80 [0.62, 0.98]). All sociodemographic characteristics were independently associated with post-concussion symptoms, as were physical IPV (total score: r = 0.28 [0.19, 0.35], p < 0.001) and sexual IPV severity (total score: r = 0.22 [0.13, 0.30], p < 0.001). In hierarchical regression analyses, controlling for sociodemographic characteristics (i.e., age, race/ethnicity, education, unemployment, and rural/urban residence) and physical and sexual IPV severity, IPV-related head injury was independently significant and accounted for significant additional variance when predicting cognitive (ΔR2 = 0.05, p < 0.001), physical (ΔR2 = 0.03, p < 0.001), emotional (ΔR2 = 0.07, p < 0.001), and total symptoms (ΔR2 = 0.06, p < 0.001). Negative-binomial regression resulted in similar findings. This study demonstrates that multiple sociodemographic and IPV history variables are related to post-concussion symptom severity, but IPV-related head injury was independently associated with greater symptom severity. Women with IPV-related head injuries may be at increased risk for unaddressed health problems spanning cognitive, physical, and emotional domains. Future research is needed to psychometrically evaluate assessment instruments for this population and to assess efficacy of interventions to address their unique health care needs.

H - 23 Post-Concussive Symptom Severity and Mental Health Status in Hispanic or Latine Youth: Implications for Generalizability.

Previous analysis in a pediatric sample demonstrated that pre-injury anxiety/depression significantly predicted post-concussive symptom severity and longer time to recovery. The current study investigated the reproducibility of results using a sample who identified as Hispanic or Latine (H/L). Participants were a subsample of H/L youths (n = 443) from an outpatient mild traumatic brain injury (mTBI)/concussion program (June 2017 - present). Eligibility criteria included: 1) mTBI (GCS ≥ 13) and 2) 5-17years of age. Families self-reported on youth's pre-injury anxiety/depression symptoms and history of psychotherapy. Concussion symptoms were measured via the Post-Concussive Symptom Inventory (PCSI) at each visit. Regression analysis controlled for baseline symptoms, days since injury, and age. Youths (M age = 13.13; SD = 3.21) with pre-injury anxiety/depression reported significantly higher PCSI scores at baseline (t(98) = -6.90, p < 0.001) and visit 1 (t(123) = -6.39, p = 0.002). They also took significantly longer to receive clearance for high risk activities (t(85) = -3.71, p < 0.001) than those without pre-injury anxiety/depression. Results of multiple regression analyses indicated that history of psychotherapy significantly predicted higher PCSI scores at visit 1 after controlling for aforementioned covariates (ꞵ= 9.95, S.E. = 3.25, p = 0.002). Consistent with previous findings, H/L youth with pre-concussion anxiety/depression reported higher symptoms and longer recovery time. However, the strongest predictor of symptoms for H/L youth was history of therapy, instead of anxiety/depression in the general sample. Variability in the strength of predictors warrants additional investigation and clinical attention to race/ethnicity to avoid overgeneralization.

Repetitive Head Injury and Cognitive, Physical, and Emotional Symptoms in Women Survivors of Intimate Partner Violence.

Many women survivors of intimate partner violence (IPV) experience repetitive head injuries in their lifetime, but limited research has examined the cumulative effects of multiple head injuries on post-concussion symptom severity in this population. This study examined how number of lifetime head injuries and episodes of loss of consciousness (LOC) due to head injuries were related to current cognitive, physical, and emotional symptoms among women survivors of IPV. Cisgender women from Kentucky were recruited following a protective order against an intimate partner, including 268 women with no reported lifetime head injuries and 250 women with one or more IPV-related head injuries (mean [M] = 17.2 head injuries, standard deviation [SD] = 50.5, median [Mdn] = 4, range = 1-515; M = 1.8 LOC episodes, SD = 4.3, Mdn = 1, range = 0-35, respectively). Participants underwent in-person interviews about lifetime physical and sexual IPV history, head injury history, and current cognitive, physical, and emotional symptoms. Sociodemographic characteristics, physical and sexual IPV severity, and current symptom severity were examined in relation to number of head injuries and LOC episodes. A higher number of head injuries was associated with greater age, White race, less than high school education, unemployment, and rural residence. No sociodemographic variables differed based on number of LOC episodes. Greater number of lifetime head injuries and LOC episodes correlated significantly with physical IPV severity (rho = 0.35, p < 0.001; rho = 0.33, p < 0.001, respectively) and sexual IPV severity (rho = 0.22, p < 0.001; rho = 0.19, p = 0.003). Greater number of head injuries and LOC episodes correlated significantly with greater cognitive (rho = 0.33, p < 0.001; rho = 0.23, p < 0.001, respectively), physical (rho = 0.36, p < 0.001; rho = 0.31, p < 0.001), emotional (rho = 0.36, p < 0.001; rho = 0.18, p = 0.004), and total symptom severity (rho = 0.39, p < 0.001; rho = 0.26, p < 0.001). In group comparisons, participant groups stratified by number of head injuries (i.e., 0, 1-3, 4+) differed in total symptom severity (p < 0.001, η2 = 0.15), with greater symptom burden associated with more head injuries. Participants with and without LOC differed in symptom severity: cognitive (p < 0.001, d = 0.45), physical (p < 0.001, d = 0.60), emotional (p = 0.004, d = 0.37), and total symptom severity (p < 0.001, d = 0.53). Group differences between participants with and without LOC remained significant after controlling for sociodemographic variables and IPV severity. There was no cumulative effect of LOC, in that participants with 1 LOC episode did not differ from participants with 2 + LOC episodes (p > 0.05). Based on hierarchical regression analyses, only physical symptoms were independently related to number of head injuries (p = 0.008, ΔR2 = 0.011) and number of LOC episodes (p = 0.014, ΔR2 = 0.021) after controlling for sociodemographic characteristics and IPV severity. Among women survivors of IPV, cumulative head injuries appear related to greater symptom severity. Greater head injury history was independently related to worse physical symptoms (e.g., headaches, dizziness, sleep problems), whereas cognitive and emotional symptoms were, in part, attributable to cumulative physical and emotional trauma due to IPV. Women survivors of IPV with repetitive head injuries have unmet neurobehavioral health needs that may benefit from targeted interventions.

Adverse Outcome Following Mild Traumatic Brain Injury Is Associated with Microstructure Alterations at the Gray and White Matter Boundary.

The gray matter/white matter (GM/WM) boundary of the brain is vulnerable to shear strain associated with mild traumatic brain injury (mTBI). It is, however, unknown whether GM/WM microstructure is associated with long-term outcomes following mTBI. The diffusion and structural MRI data of 278 participants between 18 and 65 years of age with and without military background from the Department of Defense INTRuST study were analyzed. Fractional anisotropy (FA) was extracted at the GM/WM boundary across the brain and for each lobe. Additionally, two conventional analytic approaches were used: whole-brain deep WM FA (TBSS) and whole-brain cortical thickness (FreeSurfer). ANCOVAs were applied to assess differences between the mTBI cohort (n = 147) and the comparison cohort (n = 131). Associations between imaging features and post-concussive symptom severity, and functional and cognitive impairment were investigated using partial correlations while controlling for mental health comorbidities that are particularly common among military cohorts and were present in both the mTBI and comparison group. Findings revealed significantly lower whole-brain and lobe-specific GM/WM boundary FA (p < 0.011), and deep WM FA (p = 0.001) in the mTBI cohort. Whole-brain and lobe-specific GM/WM boundary FA was significantly negatively correlated with post-concussive symptoms (p < 0.039), functional (p < 0.016), and cognitive impairment (p < 0.049). Deep WM FA was associated with functional impairment (p = 0.002). Finally, no significant difference was observed in cortical thickness, nor between cortical thickness and outcome (p > 0.05). Findings from this study suggest that microstructural alterations at the GM/WM boundary may be sensitive markers of adverse long-term outcomes following mTBI.

A-30 The Association between Pre-injury Symptoms and Self-Efficacy in Youth with Concussion

Abstract Purpose Youth’s self-efficacy for managing their recovery is associated with post-concussion symptom severity. The association between pre-injury symptoms and self-efficacy is not known. Methods Participants were 947 youth ages 9-18 (mean age=14.28, 52% female) with concussion (mean days since injury=19.11) and their caregivers. Participants and caregivers reported on pre-injury symptom domains (physical, cognitive, fatigue, and emotional) using the age-specific Post Concussion Symptom Inventory-2 (PCSI-2; 8-12 years, 13-18 years, caregiver versions). Self-efficacy for managing concussion recovery was measured using the Progressive Activities of Controlled Exertion-Self-Efficacy (PACE-SE) scale Total score. In these three groups, bivariate correlations examined associations among pre-injury symptoms and self-efficacy. Results PACE-SE Total score did not differ based on age or sex. In 9-12-year-olds (n=205), PCSI-2 self-ratings of pre-injury symptoms in the cognitive (r=-.15, p=.03) and emotional (r=-.27, p&amp;lt;.001) domains were negatively associated with the PACE-SE Total score. In 13-18-year-olds (n=742), PCSI-2 self-ratings of pre-injury symptoms in the physical (r=-.20), cognitive (r=-.23), fatigue (r=-.25), and emotional (r=-.34) domains were negatively associated with the PACE-SE Total score (all p&amp;lt;.001). PCSI-2 caregiver-ratings of pre-injury symptoms were not associated with PACE-SE Total score for either age group. Conclusions Pre-injury functioning appears to influence confidence in post-injury recovery. Management of concussion recovery should account for pre-injury functioning. Youth who report more difficulties at baseline may benefit from efforts to boost self-efficacy following injury. Future research might further investigate the relationship of the caregiver report of pre-injury functioning with self-efficacy.

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

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. To estimate MCID for the WHODAS 2.0 for mTBI. 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. 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. 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.

Early Postinjury Screen Time and Concussion Recovery.

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). 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). 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. 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.

Post-concussive symptoms mediate the relationship between sleep problems and participation restrictions among veterans with mild traumatic brain injury.

BackgroundSleep problems are common among Veterans with mild traumatic brain injury (mTBI) and may contribute to participation restrictions. However, explanatory mechanisms underlying this relationship are poorly understood. Sleep problems are associated with post-concussive symptoms (e.g., headaches). In turn, post-concussive symptoms contribute to participation restrictions. We hypothesized that post-concussive symptom severity mediates the purported relationship between sleep problems and participation restrictions among Veterans with mTBI.Materials and MethodsThis study was a retrospective analysis of clinical data among 8,733 Veterans with mTBI receiving Veterans Health Administration outpatient care. Sleep problems (yes/no) were identified using the sleep-related item from the Neurobehavioral Symptom Inventory (NSI). Post-concussive symptoms were measured using remaining NSI items. Participation restrictions were measured using the Mayo-Portland Adaptability Inventory Participation Index. We specified a latent variable path model to estimate relationships between: (1) sleep problems and three latent indicators of post-concussive symptoms [vestibular-sensory (e.g., headache)]; mood-behavioral [e.g., anxiety]; cognitive [e.g., forgetfulness]); and, (2) the three latent indicators of post-concussive symptoms and two latent indicators of participation restrictions (social and community participation [e.g., leisure activities]; productivity [e.g., financial management]). We examined the indirect effects of sleep problems upon participation restrictions, as mediated by post-concussive symptoms. Estimates were adjusted for sociodemographic factors (e.g., age), injury characteristics (e.g., blast), and co-morbid conditions (e.g., depression).Results87% of Veterans reported sleep problems. Sleep problems were associated with greater social and community participation restrictions, as mediated by mood-behavioral (β = 0.41, p < 0.001) and cognitive symptoms (β = 0.13, p < 0.001). There was no evidence that vestibular-sensory symptoms mediated this relationship (β = -0.01, p = 0.48). Sleep problems were associated with greater productivity restrictions, as mediated by vestibular-sensory (β = 0.16, p < 0.001) and cognitive symptoms (β = 0.14, p < 0.001). There was no evidence that mood-behavioral symptoms mediated this relationship (β = 0.02, p = 0.37).DiscussionFindings suggest that evidence-based sleep treatment should occupy a prominent role in the rehabilitation of Veterans with mTBI. Indirect effects of sleep problems differed when considering impact on social and community participation vs. productivity, informing individualized rehabilitative care for Veterans with mTBI.

A comparison of the functional connectome in mild traumatic brain injury and post-traumatic stress disorder.

Post-traumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) often co-occur in the context of threat to one's life. These conditions also have an overlapping symptomatology and include symptoms of anxiety, poor concentration and memory problems. A major challenge has been articulating the underlying neurobiology of these overlapping conditions. The primary aim of this study was to compare intrinsic functional connectivity between mTBI (without PTSD) and PTSD (without mTBI). The study included functional MRI data from 176 participants: 42 participants with mTBI, 67 with PTSD and a comparison group of 66 age and sex-matched healthy controls. We used network-based statistical analyses for connectome-wide comparisons of intrinsic functional connectivity between mTBI relative to PTSD and controls. Our results showed no connectivity differences between mTBI and PTSD groups. However, we did find that mTBI had significantly reduced connectivity relative to healthy controls within an extensive network of regions including default mode, executive control, visual and auditory networks. The mTBI group also displayed hyperconnectivity between dorsal and ventral attention networks and perceptual regions. The PTSD group also demonstrated abnormal connectivity within these networks relative to controls. Connectivity alterations were not associated with severity of PTSD or post-concussive symptoms in either clinical group. Taken together, the similar profiles of intrinsic connectivity alterations in these two conditions provide neural evidence that can explain, in part, the overlapping symptomatology between mTBI and PTSD.

Menstrual Cycle Function Following Concussion In Adolescent Patients

Purpose: This study sought to describe menstrual cycle patterns in acutely concussed adolescents and to investigate if cycle phase at injury influenced post-concussion cycle pattern changes or symptom endorsement. Methods: Data were collected prospectively from patients aged 13-18 years presenting to a specialty care concussion clinic for initial visit within 28 days of concussion and a follow-up visit 3-4 months post-injury. Primary outcomes included changes in menstrual cycle pattern since injury (change/no change), menstrual cycle phase at time of injury, calculated using date of last period prior to injury, and symptom severity, measured by the Post-Concussion Symptom Inventory (PCSI). Fisher’s exact tests were used to determine the association between menstrual phase at injury and change in cycle pattern at follow-up. Multiple linear regression was used to determine if menstrual phase at injury was associated with subsequent PCSI symptom severity, adjusting for age. Results: Five hundred ninety-eight post-menarchal adolescents were enrolled (mean age 15.4 ± 1.4 years) with 136(22.7%) returning for follow-up. At time of injury, 108(18.9%) were in the menstruation phase, 269(47.0%) were in the follicular phase, 105(18.4%) were in the early luteal phase, and 90(15.7%) were in the late luteal phase. Menstrual pattern change was reported in 4% of patients at initial visit and 12.5% of patients at follow-up. At 3-4 months, menstrual phase at injury was not associated with menstrual cycle changes (p = 0.18) but was associated with PCSI severity (p = 0.03). Patients injured in the early luteal phase reported the highest symptom severity at follow-up. Conclusions: One in eight adolescents reporting to clinic at 3-4 months post-concussion had experienced a change in menses. Menstrual cycle phase at time of injury was associated with post-concussion symptom severity, but not a change in menstrual pattern. Leveraging the largest study sample of post-concussion menstrual patterns to date, this study represents important foundational data regarding potential hormonal effects of concussion in adolescents. Supported by NIH R01NS097549 and T32NS043126

A Remotely Delivered Progressive Walking Intervention for Adults With Persistent Symptoms of a Mild Traumatic Brain Injury: Feasibility and Exploration of Its Impact.

IntroductionPersistent post-concussion symptoms following a mild traumatic brain injury (mTBI) can impact function and participation of adults. Physical activity is recommended to reduce symptoms and foster return to normal activities. Adults with a mTBI may have personal factors or experience accessibility issues restricting physical activity. Walking is a physical activity accessible to most that could be delivered remotely.ObjectivesDetermine the feasibility, safety, and acceptability of a remotely delivered progressive walking intervention designed for adults with persistent mTBI symptoms and explore its effects on health-related outcomes.MethodologyThis feasibility study using a single-group pre-post mixed methods convergent parallel design was conducted remotely. Adults aged 18–65 years with a mTBI reporting persistent symptoms for ≥3 months were recruited. The 8-week remote progressive walking intervention aimed to increase the weekly number of steps walked by 40% based on a 1-week baseline measured by a Fitbit Inspire 2 activity monitor. Feasibility measures were about the intervention, its remote delivery, safety, and acceptability. Health-related outcomes were post-concussion symptoms, kinesiophobia, mood, sleep, fatigue, and quality of life. Semi-structured exit interviews were recorded and transcribed verbatim. Quantitative and qualitative data were analyzed separately, and results merged, compared, and contrasted. Descriptive statistics and paired samples t-tests were used. The qualitative analyses followed an iterative content analysis approach using reflexivity and triangulation of sources.ResultsTwenty adults (16 women) aged 42.5 ± 11.51 years with persisting symptoms for 9.25 ± 6.43 months participated, adhered to 94.38% of sessions, completed the intervention, and found it to be feasible, safe and acceptable. Participants increased weekly total number of steps walked (change = 14,886 ± 18,283; t = 3.55, p = 0.002). Severity of post-concussion symptoms (change = −6.42 ± 10.69; t = −2.62, p = 0.018), kinesiophobia (change = −5 ± 6.86; t = 3.18, p = 0.005), anxiety (change = −1.53 ± 3.01; t = −2.21, p = 0.04), and fatigue (change = −10.21 ± 10.20; t = −4.37, p < 0.001) were reduced, whilst quality of life improved (change = 10.58 ± 13.35; t = 3.46, p = 0.003). Participants' perceptions corroborate most quantitative results; they felt improved self-efficacy about physical activity and provided five key recommendations.DiscussionThis study demonstrates the feasibility, safety, and acceptability of the remote 8-week progressive walking intervention, a promising approach to reduce persisting symptoms, improve physical activity level health-related outcomes and quality of life of adults with persistent post-concussion symptoms following a mTBI.

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

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. 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). 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). 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.

The Toronto Concussion Study: Sense of smell is not associated with concussion severity or recovery

ABSTRACT Objective To examine sense of smell as a biomarker for both severity and duration of post-concussion symptoms. Methods Participants were recruited prospectively from an outpatient concussion clinic. Sense of smell was assessed using the University of Pennsylvania Smell Identification Test (UPSIT) within 7 days, and 4, 8 – or 16-weeks post-injury. UPSIT normative data were used as normal controls. The main outcomes were: symptom severity on the Sport Concussion Assessment Tool 3 (SCAT3) symptom inventory and time to physician-declared recovery. Results A total of 167 participants (mean age 32.9 [SD, 12.2] years, 59% female [n = 99]) were classified at 1 week post injury as follows: severe hyposmia in 5 (3%), moderate hyposmia in 10 (6%), mild hyposmia in 48 (29%), and normosmia in 104 (62%) individuals. A convenience sample of 81 individuals with concussion were tested at follow-up. Acute impairment of sense of smell following concussion was not associated with symptom severity on the SCAT3 or time to recovery. Sense of smell was stable from baseline to follow-up in this population. Conclusion This study provides evidence that routine testing of sense of smell in individuals with concussion is not warranted as a biomarker for severity of concussion and concussion recovery.