Journal of Head Trauma Rehabilitation最新文献

Introduction: In North America, concussions are a common injury in the pediatric population. Much of the research to date has focused on biological aspects of concussion. Consideration of psychological, social and ecological factors, specifically the social determinants of health (SDH), relevant to concussion is essential to advancing the field of pediatric concussion.

Objectives: Using the WHO Conceptual Framework for Action on the Social Determinants of Health, we performed a scoping review to (1) identify and describe the research areas studied in the literature on SDH and pediatric concussion, and (2) summarize the reported findings of the included studies.

Methods: A comprehensive search for peer-reviewed articles published between 2005 and 2025, was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses - Scoping Review (PRISMA-ScR) guidelines. Selected studies were reviewed for descriptive analysis by two independent reviewers.

Results: In total, 26 studies were included in this scoping review and the topics of study were grouped into 3 main categories: (1) identification; (2) service access and utilization; and (3) outcomes. Lower socioeconomic status (SES), limited English proficiency, and housing instability were linked to a higher incidence of concussions. Non-White pediatric patients, those with public insurance, and rural residents were more likely to use emergency departments instead of specialized concussion services. Non-White participants often had shorter recovery times, while the connections between socioeconomic status, public school attendance, and recovery duration were inconsistent.

Conclusion: The findings illustrate current gaps in the literature and opportunities for actions to address SDH among children and adolescents to improve representation in concussion research, understand differences in concussion reporting and tracking and learn about and mitigate disparities in access to concussion care and treatment outcomes.

Objective: With enhancements in standard of care for sport-related concussion (SRC), there is a need to examine sex differences within the context of specific targeted treatments, like vestibular rehabilitation (VR). The primary purpose was to compare symptom severity and vestibular and ocular motor impairment between male and female adolescent athletes with SRC who received VR. The secondary purpose was to compare VR treatment time and recovery time between male and female adolescent athletes with SRC.

Setting: Specialty concussion clinic in a metropolitan area in Texas.

Participants: Male (n = 14, 30.4%) and female (n = 32, 69.6%) adolescent athletes (15.39 ± 1.11 years) in sex-comparable sports were referred to VR within 30 days after SRC.

Study design: Retrospective cohort.

Main measures: Symptom severity was measured using the Post-Concussion Symptom Scale, and vestibular and ocular motor impairment was assessed using the Vestibular Ocular Motor Screening at the first clinic visit and the VR discharge visit. The VR treatment time was the number of days from the first VR visit to the VR discharge visit. Recovery time was the number of days from injury to medical clearance from the clinic.

Results: There were no sex differences in symptom severity (P = 0.12) or vestibular ocular motor impairment at the first clinic visit. There were no sex differences in the change in symptom severity (P = 0.71) or vestibular ocular motor impairment during VR. There were no sex differences in VR treatment time (P = 0.52) or recovery time (P = 0.17).

Conclusions: There were no observed sex differences in symptom severity or vestibular and ocular motor impairment at the first clinic visit. Male and female adolescent athletes demonstrated similar benefit from, and length of, VR.

Objective: Describe the development and initial psychometric evaluation of the Boston Assessment of Traumatic Brain Injury (TBI) Lifetime, Second Edition (BATL-2).

Setting: The Translational Research Center for TBI and Stress Disorders (TRACTS) located at two large VA medical centers.

Participants: Random selection of 100 US post-9/11 military Veterans enrolled at TRACTS Boston primary site and 20 Veterans enrolled at TRACTS Houston secondary site.

Design: Secondary analysis of a prospective longitudinal cohort study.

Main measures: Boston Assessment of TBI-Lifetime (BAT-L), BATL-2, Ohio State University Traumatic Brain Injury Identification Method (OSU-TBI-ID).

Results: BATL-2 instrument development included National Institute of Neurological Disorders and Stroke (NINDS) and American Congress of Rehabilitation Medicine (ACRM) field updates to TBI diagnostics, iterative review and feedback from stakeholders, and data-driven revisions. The BATL-2 demonstrated excellent diagnostic agreement with TBI diagnosis from the OSU-TBI-ID (κ = 0.94; sensitivity 100%; specificity 87.0%-92.5%). Internal consistency and diagnostic agreement between BATL-2 and the first edition BAT-L were high (Cronbach's α = 0.83; κ = 0.94). BATL-2 demonstrated convergent validity with neurobehavioral symptoms ( r = .260, p = .012) and discriminant validity with measures of depression ( r = .004, p = .966) and tobacco use ( r = .086 to .307, p > .553). Replication in a secondary sample showed robust diagnostic agreement (κ = 0.97).

Conclusions: Results indicate that the BATL-2 is a valid and reliable measure of retrospective TBI diagnosis. Importantly, BATL-2 provides continuity of evidence-based assessment of TBI, including forward compatibility with updated field TBI diagnostic criteria while maintaining backward compatibility with BAT-L and previous TBI guidelines. The BATL-2 improves retrospective brain injury characterization by reducing administration time burden, assessing repetitive head impacts (RHI) and military occupational blast exposures (MOBE), and incorporating updated field standards.

Objective: The purpose of the study was to investigate acceptable and appropriate testing modalities for older adults with and without traumatic brain injuries (TBI) and efficient service delivery models for clinicians.

Setting: Two neurocognitive assessments were administered in telehealth settings to older adults with and without TBI.

Participants: Forty-two older adults with no more than mild cognitive impairment, 21 with a history of TBI, and 21 without (aged 71.0 ± 4.45 years) were included. All adults with TBI were in chronic stages post-TBI (5-56 years).

Design: Participants from a quasi-randomized self-management intervention study were enrolled in 2 visits. The first virtual visit included neurocognitive assessments. Assessment order was randomized, and intervention providers were blinded to the injury status.

Main measures: The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) on the QInteractive platform and CNS Vital Signs (CNSVS). Both validated assessments provide a global cognitive score and subscales. Time to administer and qualitative clinical notes on participation, acceptance, and preference (patient and clinician) were also collected.

Results: There was a positive correlation between RBANS and CNSVS, r = .710, P < .001, indicating that both assessments produced similar neurocognitive scores. Participants without TBI had higher global neurocognitive scores than participants with TBI across both RBANS (t = -4.29, P = < .001) and CNSVS (t = -2.97, P = .002). When examining subscale scores, CNSVS captured more differences in individual subscales than RBANS. The RBANS administration time (34.86 min, SD = 8.4) was longer than CNSVS (31.29 min, SD = 4.79), but did not differ across injury status (RBANS: t = 1.37, P = .179; CNSVS: t = -1.56, P = .127). Patient preference was unremarkable, and older adults were reported to participate well, but clinicians preferred CNSVS.

Conclusion: Regardless of the assessment, both were acceptable and appropriate for older adults with and without TBI. However, CNSVS was preferred by clinicians and captured more differences, suggesting an increased sensitivity for evaluating neurocognition.

Objective: To explore physicians' views and practices regarding driving following concussion, with a particular focus on return-to-drive recommendations for adolescents.

Setting: Health care.

Participants: A total of 11 participating physicians from various medical specialties, with 7 in Sports Medicine, 2 in Physical Medicine and Rehabilitation, 1 in Emergency Medicine, and 1 in Family Medicine.

Design: Qualitative interview study using virtual, semi-structured interviews.

Main measures: Views and practices regarding return-to-drive protocols for adolescent patients following concussion.

Results: Eleven interviews were conducted with 6 male and 5 female physicians. Two researchers independently coded the verbatim transcripts using systematic, open, and focused coding. Three major themes were identified regarding physicians' views and practices on return-to-drive following concussion: (1) evidence, (2) determinants, and (3) recommendations. Physicians expressed that the lack of clear evidence regarding the timing of safe return-to-drive contributed to their discomfort and infrequent discussions of the subject with their patients. The content and timing of return-to-drive discussions varied among physicians and were influenced by several factors, including the timing of initial and follow-up clinical visits, the physician's experience and comfort level, and the perceived receptivity and compliance of the adolescent with the recommendations. Physicians emphasized that return-to-drive guidelines should be tailored to each patient's unique recovery trajectory and needs, rather than following a one-size-fits-all approach.

Conclusion: These findings underscore the urgent need for evidence-based clinical guidance, particularly for adolescent drivers as they face heightened risk for both concussion and motor vehicle collisions. Currently, the absence of standardized protocol leads to inconsistent practices among physicians and inadequate guidance for recovering adolescents.

Objective: To (1) retrospectively apply the updated American Congress of Rehabilitation Medicine (ACRM) mild traumatic brain injury (mTBI) criteria to a cohort of high school athletes previously diagnosed with sport-related concussion (SRC) using prior clinical definitions, and (2) compare demographics, medical history, and recovery outcomes between those who met the full mTBI criteria versus those classified as suspected mTBI.

Setting: Outpatient Specialty Concussion Clinic.

Participants: In total, 181 concussed athletes aged 14 to 18 years were presented to clinic within 72 hours of injury. All were diagnosed with SRC by a certified athletic trainer or physician using the Concussion in Sport Group definition, which defines SRC as any traumatic blow to the head/body causing neurologic symptoms.

Design: Retrospective cohort study.

Main measures: Participants were classified as having a full or suspected mTBI based on the ACRM 2023 criteria. Full mTBIs required: (1) a plausible mechanism and either (2a) a clinical sign (eg, amnesia, loss of consciousness), or (2b) at least 2 symptoms plus a clinical examination finding. Suspected mTBIs had a plausible mechanism and at least 2 symptoms or at least 2 examination findings. Groups were compared across demographics, medical history, and recovery metrics (return-to-learn, symptom resolution, return-to-play).

Results: Of the 181 patients (mean age 16.3 ± 1.3 years; 35.9% female), 114 (63.0%) met the definition for a full mTBI, whereas 67 (37.0%) had a suspected mTBI. Significant differences included higher rates of family migraine history (24.8% vs 7.7%, P = .019) and on-field evaluations (50.4% vs 38.5%, P < .001) in the full group. No significant differences in return-to-learn (median [Mdn]: 4.0 vs 3.0), symptom resolution (Mdn: 11.0 vs 12.5), or return-to-play (Mdn: 15.0 vs 14.5) were noted (P > .05).

Conclusion: Among high school athletes with SRC, most met the updated full ACRM mTBI criteria, with the rest meeting the suspected mTBI criteria. Results suggest high sensitivity for the ACRM definition for diverse concussion presentations.

Background: Agitation is a common experience in the early stages of recovery from moderate-to-severe traumatic brain injury (TBI) at any age, but there is limited research evidence to guide best practice for children and adolescents.

Objective: We aimed to explore current approaches to the assessment and management of agitation following pediatric moderate-to-severe TBI.

Methods: In 2024, a cross-sectional anonymous survey was distributed via email to clinicians involved in care of children during early moderate-to-severe TBI recovery in Australia.

Results: Respondents were 58 clinicians (medical, nursing, and allied health) who worked in pediatric emergency, intensive care, acute, or inpatient rehabilitation settings. Findings indicated that formal measures are rarely used to evaluate, monitor, and document agitation in children with moderate-to-severe TBI in the early stages of recovery, despite a wide range of pharmacological and non-pharmacological interventions being used in its management.

Conclusion: Future research is critical to ensure that developmentally appropriate measures of agitation are implemented in clinical practice following pediatric moderate-to-severe TBI and to address the lack of evidence for the range of interventions used.

Objective: This study aimed to provide evidence on the long-term risk and comparative outcomes of hydrocephalus, a serious complication of traumatic brain injury (TBI) and hemorrhagic stroke (HS).

Setting: The study analyzed data from the Korean National Health Insurance Service-National Sample Cohort (2002-2013). Data from 2002 to 2005 were used as a washout period, and cases identified from 2005 to 2013 were included in the analysis. New-onset hydrocephalus was defined as at least 2 medical claims with code G91 of the International Classification of Diseases, 10th revision.

Participants: A total of 17 331 patients diagnosed with TBI or HS were matched with 86 655 controls using propensity score matching.

Design: A retrospective cohort study comparing patients with TBI or HS to matched controls.

Main measures: Crude incidence rates (IRs), incidence rate ratios (IRRs), and adjusted hazard ratios were estimated using time-stratified Cox models over a 9-year follow-up period.

Results: The incidence of hydrocephalus was significantly higher in the case group (IR, 1.88 per 1000 person-years) than in the control group (IR, 0.10). The overall IRR was 19.64 (95% confidence interval [CI], 13.30-29.00). Stratified analyses showed an IRR of 8.21 (95% CI, 5.32-12.68) for TBI and 35.49 (95% CI, 20.53-61.36) for HS. The adjusted hazard ratios declined over time but remained elevated for up to 6 years post-diagnosis. Risk was high in younger individuals, smokers, and alcohol users.

Conclusion: TBI and HS are associated with a substantially increased long-term risk of hydrocephalus, especially in the early years following diagnosis. HS confers a greater risk than TBI. These findings underscore the need for prolonged surveillance in high-risk individuals and appropriate management of hydrocephalus.

Objective: To examine the impact of low-level blast (LLB) exposure on cognitive functioning in combat-exposed service members and Veterans (SM/Vs), and its interaction with posttraumatic stress disorder (PTSD) and deployment-related mild traumatic brain injury (TBI).

Setting: Multi-site Department of Defense and Veterans Affairs research centers participating in the LIMBIC-CENC Prospective Longitudinal Study.

Participants: 1036 SM/Vs who deployed in support of combat operations and completed comprehensive baseline assessments between 2015 and 2023.

Design: Cross-sectional observational study using multivariate linear regression and interaction models to evaluate associations between LLB, PTSD, deployment-related mild TBI, and cognitive outcomes.

Main measures: LLB exposure was assessed using the generalized blast exposure value from the Blast Exposure Threshold Survey. Cognitive functioning was evaluated using neuropsychological tests assessing memory, attention, processing speed, executive function, and global performance. PTSD was assessed using the PTSD Checklist for DSM-5.

Results: LLB was not independently associated with poorer cognitive performance. However, LLB moderated the relationship between PTSD and memory outcomes, with significantly worse visual memory in those with PTSD and high LLB exposure. Significant interaction effects were also observed between PTSD and deployment-related TBI on verbal memory, working memory, and processing speed. PTSD demonstrated the most consistent independent associations across cognitive domains.

Conclusions: Although LLB exposure alone was not associated with cognitive deficits, it interacted with PTSD and TBI to influence cognitive performance. These findings support the need for integrated assessments of blast exposure, PTSD, and TBI history in evaluating cognitive health among SM/Vs.

Objectives: To examine the feasibility, acceptability, safety, and preliminary findings of a blended intermittent theta burst stimulation and LoveYourBrain (LYB) Yoga (iTBS + LYByoga) intervention for improving pain among Veterans with chronic mild traumatic brain injury and chronic musculoskeletal pain (mTBI + CP).

Setting: Single VA hospital.

Participants: Nineteen Veterans (68.4% men) with mTBI + CP enrolled. Fourteen Veterans met full eligibility criteria and initiated iTBS + LYByoga.

Design: Single group, open-label, mixed methods, pilot clinical trial of iTBS + LYByoga. Participants received iTBS to the motor cortex at 80% of the motor threshold immediately followed by group LYB Yoga once a week for 6 weeks.

Main measures: To assess feasibility, intervention completion rates were assessed post-treatment. To assess safety, adverse events and 17 safety indicators were collected at each intervention session. To assess acceptability, self-reported satisfaction ratings, and semi-structured qualitative interviews were assessed post-treatment. To assess preliminary outcomes, the Brief Pain Inventory (BPI) was completed pre- and post-treatment: pain severity and pain interference scores were computed.

Results: Nineteen Veterans enrolled and 14 initiated the intervention. Our sample had a 71.4% (10/14) completion rate for all 6 sessions. There were no serious adverse events. The most common side effect was headaches experienced by 3 Veterans. The self-report satisfaction ratings indicated that most Veterans (60%) rated the quality of the program "excellent." Qualitative interview data support these feasibility and acceptability findings. Mean self-reported pain severity via the BPI significantly improved (P = .0026) between pre-treatment and post-treatment (Cohen's d effect size = 1.3). Mean self-reported pain interference from the BPI did not change (P = .0609) between pre-treatment and post-treatment (Cohen's d effect size = .7).

Conclusions: Lack of serious adverse events suggests that the iTBS + LYByoga intervention is safe among veterans with mTBI + CP. The program's feasibility and acceptability coupled with improvements in self-reported pain outcomes warrants further research in a larger, randomized control trial.