Journal of Head Trauma Rehabilitation最新文献

Objective: Examine whether self-reported cognitive symptoms, an indicator of need, were associated with the likelihood that Veterans with moderate-severe traumatic brain injury (msTBI) received a cognitive rehabilitation referral. We also explored whether non-clinical factors modified the relationship between cognitive symptoms and receipt of a referral.

Setting: Veterans Health Administration (VHA).

Participants: Veterans with msTBI, determined using Comprehensive Traumatic Brain Injury Evaluation data from 2013-2023 (n = 10 790).

Design: Cross-sectional study of VHA medical record data. Modified Poisson regression modelled the likelihood of cognitive rehabilitation referral based on cognitive symptom severity and non-clinical predisposing (eg, race/ethnicity) and enabling (eg, drive time) factors. Models were specified to explain referral to occupational therapy (OT), speech-language pathology (SLP), and neuropsychology. Statistical interactions determined whether non-clinical factors modified the relationship between cognitive symptoms and referral.

Main measures: Cognitive rehabilitation referrals, identified using a validated algorithm detecting key phrases in unstructured consult data. Self-reported cognitive symptom severity measuring using the Neurobehavioral Symptom Inventory.

Results: Only 35% received a cognitive rehabilitation referral, with SLP services being the most common discipline (25%). Veterans with more severe self-reported cognitive symptoms were more likely to receive a referral (relative risk [RR], 1.06; 99% confidence interval [CI], 1.05-1.08), and this relationship was stable in discipline-specific models. However, many Veterans without a referral reported disabling cognitive challenges, indicating unmet need. Non-clinical factors-including drive time (RR, 0.86; 95% CI, 0.77-0.97) and rurality (RR, 0.92; 95% CI, 0.85-0.99)-were associated with receipt of a referral, though these relationships varied across discipline-specific models. Interactions did not provide support for non-clinical factors modifying the relationship between cognitive symptoms and receipt of a referral.

Conclusions: While cognitive rehabilitation services tend to be allocated to those in need, results revealed gaps in access. Findings can guide development of strategies expanding access to cognitive rehabilitation among Veterans with msTBI, enhancing clinical outcomes.

Objective: To investigate whether seasonality is associated with (1) concussion incidence and (2) recovery outcomes, including the time to symptom resolution (SR) and return-to-play (RTP) in Division I college football players.

Setting: Multi-institution study using the CARE Consortium database composed of 30 universities investigating the natural history of concussions between 2014 and 2020.

Participants: 682 Division I football athletes across 21 institutions who sustained a concussion during practice or competition.

Design: Prospective cohort study of NCAA Division I football players with concussion.

Main measures: Concussion incidence rates across 4 season periods (preseason, early, middle, and late-season) were analyzed using chi-square tests. Time to SR and RTP were analyzed using Kaplan-Meier curves, and Cox proportional hazards regression.

Results: Concussion incidence rates were highest during preseason (4.73 per 100 players) compared to early (2.19), middle (2.31), and late-season (2.17). The temporal distribution showed 41.9% of concussions occurred during preseason, with 19.2%, 20.1%, and 18.8% occurring during early, middle, and late-season, respectively (χ2 = 104.6, P < .001). Kaplan-Meier analysis revealed significant differences in time to SR (log-rank P = .012). Early (HR = 0.582, P < .001) and late-season (HR = 0.634, P = .002) concussions had delayed SR compared to preseason. No differences in time to RTP (log-rank P = .300) were found, although early-season concussions had a lower RTP hazard (HR = 0.703, P = .040).

Conclusions: In a multi-institution cohort of collegiate football players, preseason resulted in the highest incidence of concussions, while early and late-season concussions had significantly longer time to SR compared to preseason. These temporal patterns suggest that contextual factors may influence concussion outcomes and warrant mechanistic investigation to inform future management strategies.

Objective: Post-concussion syndrome is a challenging condition to assess and triage rehabilitation secondary to the heterogeneity of patients' presentations. The aim of the present study was to examine the effectiveness of a subgroup-informed customized rehabilitation (CR) program in adults with persistent concussion symptoms as compared to the current symptom-based treatment approach.

Setting: Rehabilitation hospital in Toronto, Ontario, Canada.

Participants: 40 adults (mean age ± SD, 39.1 ± 13.6 years) with persistent post-concussion symptoms (mean symptom duration ± SD, 5 ± 3.1 months) were recruited from various head injury clinics around the greater Toronto area.

Design: Participants underwent a comprehensive standardized clinical exam to subgroup the ostensible symptom generators into autonomic, cervical, or vestibulo-ocular. In a crossover design, participants were randomized to undertake either a CR program for 6 weeks followed by standard care (SC) for 6 weeks (Group A) or SC followed by CR (Group B). The CR program was tailored to the individual based on the findings of the exam. The SC program was reflective of symptom-based rehabilitative recommendations.

Main measures: The primary outcome measure was the Rivermead Post-Concussion Questionnaire (RPQ-3 and RPQ-13). Secondary outcome measures included the Neck Disability Index, the Patient Health Questionnaire-9 and exercise tolerance as assessed via the Buffalo Concussion Treadmill Test.

Results: Participants in Group A made a clinically meaningful and statistically significant change to the primary and secondary outcome measures at the 6-week follow-up. These changes were maintained at the 12-week follow-up. Only following the CR program did Group B demonstrate significant and clinically meaningful changes in RPQ scores, as well as significant improvements in the secondary outcome measures.

Conclusions: A shift away from symptom-based management to subgroup-informed customized rehabilitation may be key to advancing patient care and improving clinical outcomes for this population.

This Special Communication summarizes how knowledge and clinical practice have evolved over the 40 years since the Journal of Head Trauma Rehabilitation 's topical issue (volume 1, issue 2) on "Minor Head Injury." We review important insights from this 1986 issue and highlight how research since has refined our understanding of concussion/traumatic brain injury pathophysiology, recovery, and long-term effects. We also discuss shifts in terminology and outline how assessment and rehabilitation approaches have developed over time. Finally, we call attention to areas of ongoing uncertainty and innovations that could help resolve them.

This Special Communication reflects on progress in understanding the outcomes of pediatric traumatic brain injury (TBI) since the Journal of Head Trauma Rehabilitation special issue (volume 1, issue 4) on "head injury" in children appeared in 1986. We highlight the critical role that prospective, longitudinal cohort studies have played in advancing knowledge about both mild and moderate-severe pediatric TBI. We describe conceptual and methodological innovations that the past 40 years of research has spurred and summarize remaining challenges. These include the need for comparative effectiveness and randomized controlled trials to determine what interventions are effective, singly or in combination, as well as for implementation science to translate research into clinical practice, with the goal being to provide better care and improve outcomes for children with TBI and their families.

Objective: Social and cultural dynamics surrounding expectations of athletes may influence recovery after sport-related concussion. Qualitative investigations narrowly focus on reporting, or specific age groups or sports. We explore how collegiate student-athletes experience concussion recovery; manage diagnosis, symptoms, and return-to-academics and return-to-play decision-making.

Setting: Collegiate athletics at a large, private Division 1 University in Philadelphia, PA.

Participants: Twenty-two varsity student-athletes who sustained a diagnosed sport-related concussion within 1 year from start of data collection (October 1, 2022) and progressed through the return-to-play protocol, inclusive of recently graduated alumni.

Design: Qualitative interview study.

Main measures: We conducted semi-structured interviews between October 2022 and May 2023 about how experience with concussion(s) shaped their perception of risk, reporting, recovery, and that of stakeholders (teammates, coaches, athletic trainers, family members). We analyzed interview data using the framework analysis method and created a post-injury-recovery-return model to summarize participant experiences in the context of these key moments over time.

Results: Twenty-two student-athletes (women, 59.1%; White, 77.3%; 27.3% Sophomore year) representing 15 sports teams participated. The majority of respondents experienced at least 1 concussion prior to their varsity athletics concussion. Respondents reflected on 4 key moments in their experience recovering from a concussion: (1) immediately post-diagnosis, (2) during recovery, (3) decision-making about sport and academic return, and (4) return to sports and academics. We identified the importance of managing expectations, previous concussions, and emotions on recovery and return-to-academics and sport decision-making. We also found experiences were shaped by the social environment and key actors.

Conclusions: Our findings indicate that experiences after concussion are influenced by factors including expectations for recovery, managing symptoms, and navigating decision-making, and by relationships and the social environment. Findings have implications for the way concussion is managed, and the design and application of new treatment and management guidelines for concussion. Future targeted work should investigate ways to explore and measure these factors.

Objective: Using a dyadic approach with military couples, the current study examined family risk factors for chronic neurobehavioral symptoms in service members and veterans (SMVs) following a mild traumatic brain injury (MTBI).

Setting: Military Treatment Facility.

Participants: SMV ( n = 122) and intimate partner (IPs, n = 122) dyads ( N = 244).

Design: Prospective cohort.

Main measures: SMVs completed seven neurobehavioral outcome measures. Their intimate partners completed 12 health-related quality of life (HRQOL) risk factor measures. Both members of the dyad completed three family relationships risk factor measures.

Results: The number of neurobehavioral measures that were clinically elevated (≥60 T) were summed and used to classify SMVs into three outcome groups: (1) None/Few Symptoms [0-1 elevated scores]; (2) Several Symptoms [2-3 elevated scores]; and (3) Many Symptoms [4-7 elevated scores]. SMVs in the Many Symptoms group had significantly higher scores on nine family risk factor measures compared to the None/Few Symptoms group, and seven family risk factor measures compared to the Several Symptoms group. The Several Symptoms group had higher scores on one risk factor measure compared to the None/Few Symptoms group. The largest effect sizes were found for the SMV family relationships risk factor measures. SMVs were 4.2 to 13.0 times more likely to have poor neurobehavioral outcomes when they had negative versus positive family relationships.

Conclusion: An important and unique addition to the literature was the finding that a range of risk factors in the SMV's family environment were strongly associated with clinically elevated chronic neurobehavioral symptoms following an MTBI. The establishment of the Family Wellness Program within the Defense Intrepid Network will open the door for family wellness to have a long-term place in military TBI treatment programs as a holistic, family-centered interdisciplinary model of care for warfighter brain health and return to duty following a TBI, and healthy, resilient, and military ready families.

Objective: This scoping review aims to comprehensively explore the facilitators and barriers influencing the return to work (RTW) process following a concussion, with a focus on the person impacted by concussion, medical system, funder, and workplace domains.

Design: A scoping review of electronic databases, including CINAHL, Embase, MEDLINE, PsycINFO and Web of Science, was conducted to identify relevant studies published up to April 6, 2024. Studies were included if they examined factors influencing RTW following a concussion and were available in English. Data extraction, numerical analysis and deductive content analysis were performed to determine key themes from the data. Reporting guidelines provided by the PRISMA-ScR were adhered to, and the protocol has been registered and can be accessed at the Open Science Framework.

Results: Twenty studies met the inclusion criteria and were included in the review. Findings were organized into 4 main themes influencing the RTW process: the person impacted by concussion, medical system, funder, and workplace. These were further categorized into 2 subthemes: supportive elements and challenges. Various supportive elements within each theme were identified, such as individualized rehabilitation services, graduated return to work, and developing personal agency in the individual impacted by concussion. Challenges such as lack of patient education, delayed access to services, and isolating workplace accommodations were highlighted. These findings underscore the complex interplay of factors shaping the RTW trajectory post-concussion.

Conclusion: This scoping review provides a detailed examination of supportive elements and challenges in the RTW process following a concussion. The identified themes offer valuable insights for clinicians and researchers seeking to optimize RTW outcomes and support individuals re-entering the workforce after a concussion. Future research should prioritize an examination of relevant policies and practices, assessing long-term outcomes, and explore strategies to integrate support systems to enhance the RTW experience.

Objective: Mild traumatic brain injury (mTBI) may be a common precipitant of Somatic Symptom Disorder (SSD). This study examined the prevalence, correlates, predictors, and functional impact of SSD after mTBI.

Setting: Follow up of patients recruited from emergency departments and urgent care centers.

Participants: Adults with mTBI (N = 476).

Design: Secondary analysis of a clinical trial (Clinicaltrials.gov NCT04704037).

Main measures: Early illness beliefs (Illness Perceptions Questionnaire-Revised; IPQ-R) were assessed ~2 weeks after mTBI and outcomes were assessed at 6 months post-injury, including SSD symptoms (Somatic Symptom Disorder-B Criteria Scale; SSD-12), post-concussion symptoms (Rivermead Post Concussion Symptoms Questionnaire; RPQ), disability (World Health Organization Disability Assessment Schedule; WHODAS), and psychiatric diagnoses (MINI Neuropsychiatric Inventory). SSD diagnosis was operationalized as having persistent symptoms and SSD-12 ≥ 16 (≥23 in sensitivity analyses).

Results: 15-27% of the sample met criteria for SSD at 6 months post-injury. Participants with SSD reported more pain and post-concussion symptoms, and were more likely to have comorbid Major Depressive Disorder (OR = 9.1, 95% CI = 5.3, 16.2) and at least 1 anxiety disorder (OR = 5.6, 95% CI = 3.6-8.8) compared to those without SSD. Early illness beliefs, specifically that mTBI has serious life consequences (OR = 1.2, 95% CI = 1.1-1.3) and causes distress (OR = 1.1, 95% CI = 1.0-1.2), were associated with later SSD. SSD symptoms contributed to prediction of global functional disability (WHODAS) over and above post-concussion symptom severity (RPQ; ΔDeviance = 0.22, P < .001).

Conclusions: SSD after mTBI is associated with an increased burden of symptoms, comorbidity, and disability. Early identification of at-risk patients appears feasible. SSD may be a useful framework for conceptualizing poor outcome from mTBI in patients with prominent psychological distress and guiding rehabilitation.