Neuropsychological Profiles of Deployment-Related Mild Traumatic Brain Injury: A LIMBIC-CENC Study.

BACKGROUND AND OBJECTIVES: Traumatic brain injury (TBI) is a concern for US service members and veterans (SMV), leading to heterogeneous psychological and cognitive outcomes. We sought to identify neuropsychological profiles of mild TBI (mTBI) and posttraumatic stress disorder (PTSD) among the largest SMV sample to date. METHODS: We analyzed cross-sectional baseline data from SMV with prior combat deployments enrolled in the ongoing Long-term Impact of Military-relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium prospective longitudinal study. Latent profile analysis identified symptom profiles using 35 indicators, including physical symptoms, depression, quality of life, sleep quality, postconcussive symptoms, and cognitive performance. It is important to note that the profiles were determined independently of mTBI and probable PTSD status. After profile identification, we examined associations between demographic variables, mTBI characteristics, and PTSD symptoms with symptom profile membership. RESULTS: The analytic sample included 1,659 SMV (mean age 41.1 ± 10.0 years; 87% male); among them 29% (n = 480) had a history of non-deployment-related mTBI only, 14% (n = 239) had deployment-related mTBI only, 36% (n = 602) had both non-deployment and deployment-related mTBI, and 30% (n = 497) met criteria for probable PTSD. A 6-profile model had the best fit, with separation on all indicators (p < 0.001). The model revealed distinct neuropsychological profiles, representing a combination of 3 self-reported functioning patterns: high (HS), moderate (MS), and low (LS), and 2 cognitive performance patterns: high (HC) and low (LC). The profiles were (1) HS/HC: n=301, 18.1%; (2) HS/LC: n=294, 17.7%; (3) MS/HC: n=359, 21.6%; (4) MS/LC: n=316, 19.0%; (5) LS/HC: n=228, 13.7%; and (6) LS/LC: n=161, 9.7%. SMV with deployment-related mTBI tended to be grouped into lower functioning profiles and were more likely to meet criteria for probable PTSD. Conversely, SMV with no mTBI exposure or non-deployment-related mTBI were clustered in higher functioning profiles and had a lower likelihood of meeting criteria for probable PTSD. DISCUSSION: Findings suggest varied symptom and functional profiles in SMV, influenced by injury context and probable PTSD comorbidity. Despite diagnostic challenges, comprehensive assessment of functioning and cognition can detect subtle differences related to mTBI and PTSD, revealing distinct neuropsychological profiles. Prioritizing early treatment based on these profiles may improve prognostication and support efficient recovery.

Treatment of chronic symptoms following mild traumatic brain injury with transcranial LED: a sham run-in pilot study of photobiomodulation therapy.

PRIMARY OBJECTIVE: We evaluated whether photobiomodulation with red/near infrared light applied transcranially via light emitting diodes (LED) was associated with reduced symptoms and improved cognitive functioning in patients with chronic symptoms following mild traumatic brain injury. RESEARCH DESIGN: Participants (3 men, 6 women; 22-61 years-old) underwent a 6-week intervention involving 18 40-minute transcranial LED treatment sessions. METHODS AND PROCEDURES: Reliable change indices were calculated for 10 neuropsychological test scores and 3 self-report questionnaires of subjective cognition, post-concussion symptoms, and depression at baseline and following treatment. Questionnaires were also administered after 2-week sham and at 1-month and 2-month follow-ups. MAIN OUTCOME AND RESULTS: Only 2 participants improved on neuropsychological testing. On questionnaires, 4 reported improved cognition, 5 reported improved post-concussion symptoms, and 3 reported improved depression. Significant improvement in 2 or more domains was reported by 4 participants and mostly maintained at both follow-ups. CONCLUSIONS: Most participants did not improve on neuropsychological testing. A minority self-reported improvement in symptoms, potentially explained by the intervention, psychiatric medication changes, placebo effects, or other factors. Selecting participants with different clinical characteristics, and dosing and delivery system changes, may produce different results. A study design accounting for placebo effects appears warranted in future trials.

Exploring the association between cognitive activity and symptom resolution following concussion in adolescents aged 11-17 years.

OBJECTIVE: As opposed to postconcussion physical activity, the potential influence of cognitive activity on concussion recovery is not well characterised. This study evaluated the intensity and duration of daily cognitive activity reported by adolescents following concussion and examined the associations between these daily cognitive activities and postconcussion symptom duration. METHODS: This study prospectively enrolled adolescents aged 11-17 years with a physician-confirmed concussion diagnosis within 72 hours of injury from the emergency department and affiliated concussion clinics. Participants were followed daily until symptom resolution or a maximum of 45 days postinjury to record their daily cognitive activity (intensity and duration) and postconcussion symptom scores. RESULTS: Participants (n=83) sustained their concussion mostly during sports (84%), had a mean age of 14.2 years, and were primarily male (65%) and white (72%). Participants reported an average of 191 (SD=148), 166 (SD=151) and 38 (SD=61) minutes of low-intensity, moderate-intensity and high-intensity daily cognitive activity postconcussion while still being symptomatic. Every 10 standardised minutes per hour increase in moderate-intensity or high-intensity cognitive activities postconcussion was associated with a 22% greater rate of symptom resolution (adjusted hazard ratio (aHR) 1.22, 95% CI 1.01 to 1.47). Additionally, each extra day's delay in returning to school postconcussion was associated with an 8% lower rate of symptom resolution (aHR 0.92, 95% CI 0.85 to 0.99). CONCLUSION: In adolescents with concussion, more moderate-high intensity cognitive activity is associated with faster symptom resolution, and a delayed return to school is associated with slower symptom resolution. However, these relationships may be bidirectional and do not necessarily imply causality. Randomised controlled trials are needed to determine if exposure to early cognitive activity can promote concussion recovery in adolescents.

A review of the personality traits in post-concussion syndrome.

INTRODUCTION: Various manifestations ranging from physical symptoms to cognitive and emotional impairments could often be seen following head concussions that lead to mild traumatic brain injury (mTBI). These symptoms are commonly comprising the post-concussion syndrome (PCS) and their resolution could be influenced by multiple factors. Personality traits have been suggested as potential risk factors for the emergence and persistence of PCS. In this study, we aimed to investigate the possible predisposition to PCS given by certain personality traits. METHODS: Prospective cohort studies, observational studies, and cross-phenotype polygenic risk score analyses were selected from the main scientific databases (PubMed/Medline, Scopus, EMBASE, Web of Science) based on multiple-step screening, using keywords (such as "personality traits", "post-concussion syndrome", "traumatic brain injury", "anxiety", "depression", "resilience", and "somatization") and inclusion/exclusion criteria (English written studies available in full text presenting relevant data on TBI patients and their personality traits; reviews, animal studies, and studies not written in English, not available in full text, or not presenting full demographical and clinical data were excluded). The investigated personality traits included emotional reserve, somatic trait anxiety, embitterment, mistrust, parental anxiety, state anxiety, trait anxiety, anxiety sensitivity, pain catastrophizing, helplessness, sports-concussion symptom load, and cognitive resilience. RESULTS: The reviewed data from 16 selected studies suggested that personality traits play an essential role in the development and persistence of PCS. Emotional reserve, cognitive resilience, and lower levels of somatic trait anxiety were associated with better outcomes in PCS. However, higher levels of anxiety sensitivity, pain catastrophizing, helplessness, and sports-concussion symptom load were associated with worse outcomes in PCS. Parental anxiety was not associated with persistent symptoms in children following concussion. Despite the statistical analysis regarding the included publications bias was low, further studies should further investigate the correlation between TBI and some personality traits, as some of the selected studies did not included healthy individuals and their psychological profiles for comparison and correlation analysis. CONCLUSION: Personality traits may help predict the development and persistence of PCS following mTBI. Understanding the personality traits roles in PCS could assist the development of targeted interventions for the prevention and treatment of PCS. Further research is needed to better understand the complex interactions between personality traits, neurobiological factors, and psychosocial factors in PCS.

Cognition and post-concussive symptom status after pediatric mild traumatic brain injury.

Cognitive impairment and post-concussive symptoms (PCS) represent hallmark sequelae of pediatric mild traumatic brain injury (pmTBI). Few studies have directly compared cognition as a function of PCS status longitudinally. Cognitive outcomes were therefore compared for asymptomatic pmTBI, symptomatic pmTBI, and healthy controls (HC) during sub-acute (SA; 1-11 days) and early chronic (EC; approximately 4 months) post-injury phases. We predicted worse cognitive performance for both pmTBI groups relative to HC at the SA visit. At the EC visit, we predicted continued impairment from the symptomatic group, but no difference between asymptomatic pmTBI and HCs. A battery of clinical (semi-structured interviews and self-report questionnaires) and neuropsychological measures were administered to 203 pmTBI and 139 HC participants, with greater than 80% retention at the EC visit. A standardized change method classified pmTBI into binary categories of asymptomatic or symptomatic based on PCS scores. Symptomatic pmTBI performed significantly worse than HCs on processing speed, attention, and verbal memory at SA visit, whereas lower performance was only present for verbal memory for asymptomatic pmTBI. Lower performance in verbal memory persisted for both pmTBI groups at the EC visit. Surprisingly, a minority (16%) of pmTBI switched from asymptomatic to symptomatic status at the EC visit. Current findings suggest that PCS and cognition are more closely coupled during the first week of injury but become decoupled several months post-injury. Evidence of lower performance in verbal memory for both asymptomatic and symptomatic pmTBI suggests that cognitive recovery may be a process separate from the resolution of subjective symptomology.

The Relationship Between Parental and Family Functioning and Post-Concussive Symptoms After Pediatric Mild Traumatic Brain Injury: A Scoping Review.

This scoping review aimed to address the following questions: (1) Does mild traumatic brain injury (mTBI) result in more parental distress or poorer family functioning than other injuries? (2) Does pre-injury or acute parental distress and family functioning predict post-concussive symptoms (PCS) after mTBI? and (3) Do acute PCS predict later parental distress and family functioning? The subjects of this review were children/adolescents who had sustained an mTBI before age 18 and underwent assessment of PCS and parent or family functioning. MEDLINE®, PsycInfo, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, and CENTRAL databases were searched to identify original, empirical, peer-reviewed research published in English. PCS measures included parent- and child-reported symptom counts and continuous scales. Parent and family measures assessed parental stress, psychological adjustment, anxiety, psychiatric history, parent-child interactions, family burden, and general family functioning. A total of 11,163 articles were screened, leading to the inclusion of 15 studies, with 2569 participants (mTBI = 2222; control = 347). Collectively, the included articles suggest that mTBI may not result in greater parental distress or poorer family functioning than other types of injuries. Pre-injury or acute phase parental and family functioning appears to predict subsequent PCS after mTBI, depending on the specific family characteristic being studied. Early PCS may also predict subsequent parental and family functioning, although findings were mixed in terms of predicting more positive or negative family outcomes. The available evidence suggests that parent and family functioning may have an important, perhaps bidirectional, association with PCS after pediatric mTBI. However, further research is needed to provide a more thorough understanding of this association.

The protective role of resilience in the reporting of post-concussive symptoms within a non-clinical sample.

Objective: Despite being common following a brain injury, post-concussive symptoms (PCS) are highly prevalent in healthy and non-concussed individuals. Psychosocial factors likely subserve the maintenance of symptoms, and numerous studies have identified prominent risk factors associated with post-concussive symptom reporting (e.g. history of depression). However, few studies have investigated protective factors in this context. The aim of the current study was to examine the relationship between resilience and PCS, and to identify the factors subserving resilience within this relationship. Method: Healthy and non-concussed participants (n = 283, Mage = 22.70 years) completed questionnaires examining PCS (Rivermead Post-Concussion Symptom Questionnaire) and resilience (Resilience Scale for Adults), together with a screener of background demographic/clinical factors. Results: Resilience negatively predicted PCS above and beyond the effect of demographic and clinical factors previously implicated in the reporting of PCS. Interestingly, heightened "perception of self" was the resilience factor uniquely associated with PCS symptoms. The final model accounted for 33% of the variance in PCS. Overall, female gender, a history of headaches, and diagnoses of ADHD and depression, and reduced "perception of self" were all predictive of greater PCS (ps < .05). Conclusion: Resilience, particularly perception of self, is a positive protective factor in the reporting of PCS. These findings highlight the importance of early identification of less resilient individuals following trauma-such as an mTBI and provide a potential rationale for the incorporation of resilience-based rehabilitation programs into the recovery process, particularly those that promote greater self-efficacy and self-competency.

Relations between concussion symptoms and depression among patients with mild traumatic brain injury: A moderated mediation model.

INTRODUCTION: Concussion symptoms following a traumatic accident are both common and known to adversely affect mental health and recovery in patients with traumatic brain injury. Depression, highly prevalent among patients with traumatic brain injury, is also associated with the important factors of sleep quality and resilience. However, the mediator and moderator roles of depression following concussion in patients with traumatic brain injury have been underexplored. The aims of this study were to investigate the mediating role of sleep quality in the relation between concussion symptoms and depression and to examine the moderating effect of resilience on this mediated model. DESIGN: Cross-sectional pretest data analysis of a randomized controlled trial. METHODS: A total of 249 adult patients with mild traumatic brain injury (Glasgow Coma Scale 13-15) at admission following brain injury were surveyed at a medical center in Taipei, Taiwan. The outcome variables were concussion symptoms (Rivermead Post-Concussion Symptom Questionnaire), sleep quality (Pittsburgh Sleep Quality Index), resilience (Resilience Scale for Adults), and depression (Beck Depression Inventory II). These data were analyzed using moderated mediation regressions with the SPSS PROCESS macro. RESULTS: In patients with mild traumatic brain injury, there was a significant positive relation between concussion symptoms and depression, of which sleep quality was a significant mediator. Additionally, resilience had a negative moderating effect on the relations between sleep quality and depression. Patients with less resilience showed a stronger negative effect of sleep quality on depression. CONCLUSION: Our findings suggest that ameliorating both concussion symptoms and sleep disturbance is important for reducing the risk of depression in patients with mild traumatic brain injury, especially in those patients with less resilience. CLINICAL RELEVANCE: It is essential for clinical nurses to develop interventions for patients with mild traumatic brain injury that will improve their sleep quality, while strengthening their resilience, to alleviate depression.

Change in health-related quality of life and functional disability over time post-concussion in youth.

PURPOSE: Concussions can have detrimental on children's cognitive, emotional, behavioral, and/or social functioning. We sought to examine changes in health-related quality of life (HRQOL) and functional disability from pre-injury to 1-week post-concussion, and to symptom resolution among youth ages 11-17 with a concussion. METHODS: In this prospective, longitudinal cohort study, 83 concussed youth, ages 11-17, self-reported post-concussion symptoms daily as well as HRQOL and functional disability at baseline (pre-injury, retrospective), 1-week post-concussion, and symptom resolution. We modeled changes in overall and sub-scale HRQOL and functional disability scores over time from pre-injury to 1-week post-concussion and from 1-week post-concussion to symptom resolution using a piecewise linear mixed model, adjusting for potential covariables. Estimated fixed effects with a corresponding adjusted coefficient (beta), along with their 95% confidence intervals are presented. RESULTS: Overall HRQOL worsened from pre-injury to 1-week post-injury (ß = - 5.40, 95%CI - 9.22, - 1.58) but did not change from 1-week post-injury to symptom resolution. Physical HRQOL worsened from pre-injury to 1-week post-injury (ß = - 9.90, 95%CI - 14.65, - 5.14) but improved from 1-week post-injury to symptom resolution (ß = 1.64, 95%CI 0.50, 2.78), while psychosocial HRQOL showed no change over time. Functional disability worsened from pre-injury to 1-week post-injury (ß = 8.36, 95%CI 5.93, 10.79) but with no change from 1-week post-injury to symptom resolution. Youth with symptom duration > 14 days reported worse HRQOL and functional disability than those who recovered in ≤ 14 days and greater daily post-concussion symptom scores were associated with worse HRQOL and functional disability. CONCLUSION: Concussions have a negative impact on overall and physical HRQOL and functional disability in youth acutely post-injury. Ratings of HRQOL could be used to inform clinical treatment decisions to assist with the recovery process.

Investigation of long-term symptoms and influencing factors in patients with mild traumatic brain injury: A cross-sectional study.

BACKGROUND: Traumatic brain injury is the leading cause of death and disability in individuals under the age of 45, which places a heavy disease burden on patients and society. However, the prevalence of long-term symptoms in individuals who suffered from mild traumatic brain injury and how psychosocial factors affect their long-term symptoms remain unclear. OBJECTIVE: To determine howpsychosocial factors influence long-term symptomsin individuals who suffered from mild traumatic brain injury as well as the prevalence of long-term symptoms. METHODS: A demographic characteristics questionnaire, adapted self-report questionnaire of family relationship quality, revised Chinese version of the disease perception questionnaire, Rivermead postconcussion syndrome symptom questionnaire, Glasgow Outcome Scale-Extended, and Brief Symptoms Inventory 18 were used to collect data anonymously. Psychosocial factors associated with long-term symptoms in individuals who suffered from mild traumatic brain injury weremeasuredusingmultiple linear regression. RESULTS: More than half of individuals who suffered from mild traumatic brain injury showed at least 1 long-term symptom after injury. Our results indicated that family relationship quality, disease perception, and demographic characteristics were related to the long-term symptoms of individuals who suffered from mild traumatic brain injury. CONCLUSIONS: Our study shows that theprevalence of long-term symptomsfollowingmild traumatic brain injuryishigh. Psychosocial factors are related to patients' long-term symptoms. The findings indicate that healthcare administrators ought to adopt a robust health promotion strategy that prioritizes familial support and health education of diseases to ameliorate long-term symptoms in individuals who suffered from mild traumatic brain injury.

A Framework for Understanding the Contribution of Psychosocial Factors in Biopsychosocial Explanatory Models of Persistent Postconcussion Symptoms.

Biopsychosocial models are currently used to explain the development of persistent postconcussion symptoms (PPCS) following concussion. These models support a holistic multidisciplinary management of postconcussion symptoms. One catalyst for the development of these models is the consistently strong evidence pertaining to the role of psychological factors in the development of PPCS. However, when applying biopsychosocial models in clinical practice, understanding and addressing the influence of psychological factors in PPCS can be challenging for clinicians. Accordingly, the objective of this article is to support clinicians in this process. In this Perspective article, we discuss current understandings of the main psychological factors involved in PPCS in adults and summarize these into 5 interrelated tenets: preinjury psychosocial vulnerabilities, psychological distress following concussion, environment and contextual factors, transdiagnostic processes, and the role of learning principles. With these tenets in mind, an explanation of how PPCS develop in one person but not in another is proposed. The application of these tenets in clinical practice is then outlined. Guidance is provided on how these tenets can be used to identify psychosocial risk factors, derive predictions, and mitigate the development of PPCS after concussion from a psychological perspective within biopsychosocial conceptualizations. IMPACT: This Perspective helps clinicians apply biopsychosocial explanatory models to the clinical management of concussion, providing summary tenets that can guide hypothesis testing, assessment, and treatment.

Identifying Unique Symptom Groups Following Mild Traumatic Brain Injury Using the Neurobehavioral Symptom Inventory and PTSD Checklist-5 in Military Personnel: A Bifactor Analysis.

OBJECTIVE: To identify both shared and unique groups of posttraumatic stress and postconcussive symptoms using bifactor analysis. SETTING: Two large military outpatient traumatic brain injury (TBI) rehabilitation clinics in the Southwestern United States. PARTICIPANTS: A sample of 1476 Active Duty Service Members seeking treatment for a mild TBI sustained more than 30 days previously, without history of moderate or severe TBI, who completed measures of postconcussive and posttraumatic stress symptoms assessed at clinic intake. DESIGN: Observational, correlational study with data taken from an institutional review board-approved clinical registry study. MAIN MEASURES: Neurobehavioral Symptom Inventory (NSI) and Posttraumatic Stress Disorder (PTSD) Checklist for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) ( DSM-V ) (PCL-5). Concurrent measures were Patient Health Questionnaire (PHQ-8), Pittsburgh Sleep Quality Index (PSQI), and Headache Impact Test (HIT-6). RESULTS: Results identified a bifactor model demonstrating unique posttraumatic stress, depressive, cognitive, and neurological/somatic symptom groups that were still evident after accounting for a universal factor representing general distress. These symptom groups were differentially related to concurrently measured clinical outcomes. CONCLUSION: Use of a bifactor structure may help derive clinically useful signals from self-reported symptoms among Active Duty Service Members seeking outpatient treatment for mild TBI.

Post-Concussion Symptoms, Cognition and Brain Connectivity in an Australian Undergraduate Population: A Quantitative Electroencephalography Study.

BACKGROUND: An estimated 99 in 100,000 people experience a traumatic brain injury (TBI), with 85% being mild (mTBI) in nature. The Post-Concussion Symptom Scale (PCSS), is a reliable and valid measure of post-mTBI symptoms; however, diagnostic specificity is challenging due to high symptom rates in the general population. Understanding the neurobiological characteristics that distinguish high and low PCSS raters may provide further clarification on this phenomenon. AIM: To explore the neurobiological characteristics of post-concussion symptoms through the association between PCSS scores, brain network connectivity (using quantitative electroencephalography; qEEG) and cognition in undergraduates. HYPOTHESES: high PCSS scorers will have (1) more network dysregulation and (2) more cognitive dysfunction compared to the low PCSS scorers. METHODS: A sample of 40 undergraduates were divided into high and low PCSS scorers. Brain connectivity was measured using qEEG, and cognition was measured via neuropsychological measures of sustained attention, inhibition, immediate attention, working memory, processing speed and inhibition/switching. RESULTS: Contrary to expectations, greater frontoparietal network dysregulation was seen in the low PCSS score group (p = 0.003). No significant difference in cognitive dysfunction was detected between high and low PCSS scorers. Post-hoc analysis in participants who had experienced mTBI revealed greater network dysregulation in those reporting a more recent mTBI. CONCLUSIONS: Measuring post-concussion symptoms alone is not necessarily informative about changes in underlying neural mechanisms. In an exploratory subset analysis, brain network dysregulation appears to be greater in the early post-injury phase compared to later. Further analysis of underlying PCSS constructs and how to measure these in a non-athlete population and clinical samples is warranted.

Intensive Outpatient Program Response Among Service Members With Mild Traumatic Brain Injury: Change Between Distinct Post-Concussive Symptom Subgroups.

OBJECTIVE: Among service members (SMs) with mild traumatic brain injury (mTBI) admitted to an intensive outpatient program (IOP), we identified qualitatively distinct subgroups based on post-concussive symptoms (PCSs) and characterized changes between subgroups from admission to discharge. Further, we examined whether co-morbid posttraumatic stress disorder (PTSD) influenced changes between subgroups. DESIGN: Quasi-experimental. Latent transition analysis identified distinctive subgroups of SMs and examined transitions between subgroups from admission to discharge. Logistic regression examined the effect of PTSD on transition to the Minimal subgroup (low probability of any moderate-very severe PCS) while adjusting for admission subgroup designation. SETTING: National Intrepid Center of Excellence (NICoE) at Walter Reed National Military Medical Center. PARTICIPANTS: 1141 active duty SMs with persistent PCS despite prior treatment (N=1141). INTERVENTIONS: NICoE 4-week interdisciplinary IOP. MAIN OUTCOME MEASURE(S): Subgroups identified using Neurobehavioral Symptom Inventory items at admission and discharge. RESULTS: Model fit indices supported a 7-class solution. The 7 subgroups of SMs were distinguished by diverging patterns of probability for specific PCS. The Minimal subgroup was most prevalent at discharge (39.4%), followed by the Sleep subgroup (high probability of sleep problems, low probability of other PCS; 26.8%). 41% and 25% of SMs admitted within the Affective (ie, predominantly affective PCS) and Sleep subgroups remained within the same group at discharge, respectively. The 19% of SMs with co-morbid PTSD were less likely to transition to the Minimal subgroup (odds ratio=0.28; P<.001) and were more likely to remain in their admission subgroup at discharge (35.5% with PTSD vs 22.2% without). CONCLUSIONS: Most of SMs achieved symptom resolution after participation in the IOP, with most transitioning to subgroups characterized by reduced symptom burden. SMs admitted in the Affective and Sleep subgroups, as well as those with PTSD, were most likely to have continuing clinical needs at discharge, revealing priority targets for resource allocation and follow-up treatment.

A Prospective Cohort Study of the Association Between Preinjury Psychosocial Function and Postconcussive Symptoms in Pediatric Mild Traumatic Brain Injury: An A-CAP Study.

OBJECTIVE: We evaluated the moderating effect of preinjury psychosocial function on postconcussion symptoms for children with mild traumatic brain injury (mTBI). DESIGN, SETTING, AND POPULATION: We conducted a prospective cohort study of children ages 8.0 to 16.9 years with mTBI ( n = 633) or orthopedic injury (OI; n = 334), recruited from 5 pediatric emergency departments from September 2016 to December 2018. MAIN MEASURES: Participants completed baseline assessments within 48 hours of injury, and postconcussion symptoms assessments at 7 to 10 days, weekly to 3 months, and biweekly to 6 months post-injury. Preinjury psychosocial function was measured using parent ratings on the Pediatric Quality of Life Inventory (PedsQL) and the Strengths and Difficulties Questionnaire (SDQ), retrospectively evaluating their child's status prior to the injury. Parent and child ratings on the Health and Behavior Inventory (HBI) (cognitive and somatic subscales) and the Post-Concussion Symptom Interview (PCS-I) were used as measures of postconcussion symptoms. We fitted 6 longitudinal regression models, which included 747 to 764 participants, to evaluate potential interactions between preinjury psychosocial function and injury group as predictors of child- and parent-reported postconcussion symptoms. RESULTS: Preinjury psychosocial function moderated group differences in postconcussion symptoms across the first 6 months post-injury. Higher emotional and conduct problems were significantly associated with more severe postconcussion symptoms among children with mTBI compared with OI. Wald's χ 2 for interaction terms (injury group × SDQ subscales) ranged from 6.3 to 10.6 ( P values <.001 to .043) across parent- and child-reported models. In contrast, larger group differences (mTBI > OI) in postconcussion symptoms were associated with milder hyperactivity (Wald's χ 2 : 15.3-43.0, all P < .001), milder peer problems (Wald's χ 2 : 11.51, P = .003), and higher social functioning (Wald's χ 2 : 12.435, P = .002). CONCLUSIONS: Preinjury psychosocial function moderates postconcussion symptoms in pediatric mTBI, highlighting the importance of assessing preinjury psychosocial function in children with mTBI.

Relationship between psychosocial and psychiatric risk factors and poor long-term outcome following mild traumatic brain injury: A systematic review.

BACKGROUND AND PURPOSE: Mild traumatic brain injury (mTBI) has an estimated worldwide incidence of >60 million per year, and long-term persistent postconcussion symptoms (PPCS) are increasingly recognized as being predicted by psychosocial variables. Patients at risk for PPCS may be amenable to closer follow-up to treat modifiable symptoms and prevent chronicity. In this regard, similarities seem to exist with psychosocial risk factors for chronicity in other health-related conditions. However, as opposed to other conditions, no screening instruments exist for mTBI. METHODS: A systematic search of the literature on psychological and psychiatric predictors of long-term symptoms in mTBI was performed by two independent reviewers using PubMed, Embase, and Web of Science. RESULTS: Fifty papers were included in the systematic analysis. Anxiety, depressive symptoms, and emotional distress early after injury predict PPCS burden and functional outcome up to 1 year after injury. In addition, coping styles and preinjury psychiatric disorders and mental health also correlate with PPCS burden and functional outcome. Associations between PPCS and personality and beliefs were reported, but either these effects were small or evidence was limited. CONCLUSIONS: Early psychological and psychiatric factors may negatively interact with recovery potential to increase the risk of chronicity of PPCS burden after mTBI. This opens opportunities for research on screening tools and early intervention in patients at risk.

Developing multivariable models for predicting headache improvement in patients with acute post-traumatic headache attributed to mild traumatic brain injury: A preliminary study.

OBJECTIVES/BACKGROUND: Post-traumatic headache (PTH) is a common symptom after mild traumatic brain injury (mTBI). Although there have been several studies that have used clinical features of PTH to attempt to predict headache recovery, currently no accurate methods exist for predicting individuals' improvement from acute PTH. This study investigated the utility of clinical questionnaires for predicting (i) headache improvement at 3 and 6 months, and (ii) headache trajectories over the first 3 months. METHODS: We conducted a clinic-based observational longitudinal study of patients with acute PTH who completed a battery of clinical questionnaires within 0-59 days post-mTBI. The battery included headache history, symptom evaluation, cognitive tests, psychological tests, and scales assessing photosensitivity, hyperacusis, insomnia, cutaneous allodynia, and substance use. Each participant completed a web-based headache diary, which was used to determine headache improvement. RESULTS: Thirty-seven participants with acute PTH (mean age = 42.7, standard deviation [SD] = 12.0; 25 females/12 males) completed questionnaires at an average of 21.7 (SD = 13.1) days post-mTBI. The classification of headache improvement or non-improvement at 3 and 6 months achieved cross-validation area under the curve (AUC) of 0.72 (95% confidence interval [CI] 0.55 to 0.89) and 0.84 (95% CI 0.66 to 1.00). Sub-models trained using only the top five features still achieved 0.72 (95% CI 0.55 to 0.90) and 0.77 (95% CI 0.52 to 1.00) AUC. The top five contributing features were from three questionnaires: Pain Catastrophizing Scale total score and helplessness sub-domain score; Sports Concussion Assessment Tool Symptom Evaluation total score and number of symptoms; and the State-Trait Anxiety Inventory score. The functional regression model achieved R = 0.64 for modeling headache trajectory over the first 3 months. CONCLUSION: Questionnaires completed following mTBI have good utility for predicting headache improvement at 3 and 6 months in the future as well as the evolving headache trajectory. Reducing the battery to only three questionnaires, which assess post-concussive symptom load and biopsychosocialecologic factors, was helpful to determine a reasonable prediction accuracy for headache improvement.

Sex predicts post-concussion symptom reporting, independently of fatigue and subjective sleep disturbance, in premorbidly healthy adults after mild traumatic brain injury.

The relationship between sex and post-concussion symptom (PCS) reporting after mild traumatic brain injury (mTBI) is not well understood. Subjective sleep disturbance and fatigue impact PCS reporting after mTBI and show sex differences in the normal population. This study investigated whether sex had a relationship with PCS reporting after mTBI, independently of self-reported sleep disturbance and fatigue. Ninety-two premorbidly healthy adults in the post-acute period after mTBI completed the Rivermead Post-Concussion Symptoms Questionnaire, the Pittsburgh Sleep Quality Index, the Multidimensional Fatigue Inventory and measures of depression, anxiety and post-traumatic stress symptomatology. Females (n = 23) demonstrated higher levels of fatigue (p = .019) and greater psychological distress (p = .001) than males (n = 69), but equivalent levels of sleep disturbance (p = .946). Bootstrapping analyses were undertaken because PCS responses were not normally distributed. Female sex predicted greater PCS reporting (p = .001), independently of subjective sleep disturbance, fatigue, psychological distress and litigation status. The current findings support and extend previous work showing premorbidly healthy females are at higher risk of experiencing elevated PCS after mTBI than males in the post-acute period after mTBI. It may be beneficial for clinicians to be particularly sensitive to increased symptom reporting after mTBI in females, irrespective of sleep quality, fatigue or psychological status.

Concurrent Psychosocial Concerns and Post-Concussive Symptoms Following Pediatric mTBI: An A-CAP Study.

OBJECTIVES: To measure the association between psychosocial problems and persistent post-concussive symptoms (PCS) in youth who were seen in the emergency department with mild traumatic brain injury (mTBI) or orthopedic injury (OI). METHODS: From a larger prospective cohort study, Advancing Concussion Assessment in Pediatrics (A-CAP), 122 child-guardian pairs who presented to the emergency department with mTBI (N = 70) or OI (N = 52) were recruited for this cross-sectional sub-study. Each pair completed 2 measures assessing PCS burden at 2 weeks, 3 months, and 6 months post-injury. At one visit, pairs concurrently completed MyHEARTSMAP, a comprehensive, psychosocial self-assessment tool to evaluate 4 domains of mental wellness. RESULTS: When measured at the same visit, children who self-reported moderate or severe Psychiatry domain concerns concurrently experienced a greater burden of cognitive symptoms (ß = 5.49; 0.93-10.05) and higher overall PCS count (ß = 2.59; 0.70-4.48) after adjusting for covariables, including retrospective pre-injury symptoms and injury group. Additionally, reports indicating mild Function domain severity were associated with increased cognitive (ß = 3.34; 95% CI: 0.69-5.99) and somatic symptoms (ß = 6.79; 2.15-11.42) and total symptom count (ß = 1.29; 0.18-2.39). CONCLUSION: Increasing severity in multiple domains of mental health is associated with more PCS in youth. While the differences in PCS between the mTBI and OI groups appeared somewhat larger for children with more mental health concerns, the interaction was not statistically significant; larger sample sizes are needed to evaluate the moderating effect of psychosocial difficulties on post-concussion symptoms.

Association of Sleep Disturbance With Neurocognition, Symptom Severity, and Recovery in Pediatric Concussion: A 10-Year Retrospective Analysis of a Tertiary Referral Concussion Clinic.

OBJECTIVES: To investigate the relationship between sleep disturbance, neurocognition, symptom severity, and recovery in children and adolescents with concussion. Sex-related comparisons were also examined. SETTING: Pediatric tertiary referral concussion clinic. PARTICIPANTS: Children and adolescents (aged 6-18 years; n = 554) diagnosed with concussion. DESIGN: Cross-sectional retrospective study. MAIN MEASURES: Assessment data were obtained from Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) Applications. Sleep disturbance was quantified using the sleep-related domains of the Post-Concussion Symptom Scale (PCSS) and self-report sleep duration. Sleep duration was categorized as short (<7 hours), intermediate (7-9 hours), and long (≥9 hours). Outcome measures included neurocognition, measured via composite scores of ImPACT cognitive domains (verbal memory, visual memory, visual motor speed, reaction time); symptom severity, using the PCSS; and concussion recovery time (days). RESULTS: Short sleep resulted in significantly poorer verbal memory ( P = .03), visual memory ( P = .02), and reaction time ( P = .01). Sleep disturbance was strongly associated with total symptom burden (ρ = 0.90, P < .001). Recovery time, median (interquartile range), was significantly prolonged with short sleep, 61 (30-136) days, compared with intermediate, 38 (21-72) days, and long, 34 (19-71) days, sleep ( P < .001). Overall, female participants demonstrated significantly longer recovery times than male participants (mean 91 ± 95 vs 58 ± 85 days, P < .001). Females exhibited similar concussion recovery times irrespective of reported sleep duration ( P = .95), whereas mean recovery time in males was significantly longer with short sleep (84 ± 82 days) than with intermediate (61 ± 106 days) and long (49 ± 62 days) sleep ( P < .001). CONCLUSION: Sleep disturbance following concussion poses as a promising modifiable risk factor to alleviate postinjury impairments, including cognitive deficits and symptom burden. Female children were found to experience more severe concussion symptoms and protracted recovery times than their male counterparts. Investigations into the factors that may contribute to sex-related differences following concussion are warranted.